Spondyloarthropathies

Question 1

What are spondyloarthropathies?

Answer 1

Inflammatory conditions with axial and/ or peripheral arthritis
Negative rheumatoid factor
Usually asymmetric arthritis
Enthesitis can be a feature
Can be associated with HLA-B27

Question 2

What are some extra-articular features of spondyloarthropathies?

Answer 2

Uveitis, inflammatory bowel disease and psoriasis

Question 3

What are some different clinical presentations?

Answer 3

Axial spondyloarthropathy - radiographic and non-radiographic (seen on MRI only)
Psoriatic arthritis
Enteropathic related arthritis
Reactive arthritis
Undifferentiated SqA

Question 4

What is axial spondyloarthropathy?

Answer 4

Chronic inflammatory rheumatoid disorder with a predilection for axial skeleton and entheses

Question 5

When is the onset for axial spondyloarthropathy?

Answer 5

Onset below 45 years and often younger
Classic is late teen early 20s/30s
Prevalence varies around the world

Question 6

What are the symptoms of SpA?

Answer 6

Lower back pain before 35 years
Waking up in night with pain
Buttock pain
Improvement with movement and NSAIDs
Current of past or present inflammatory arthritis - IBD, psoriasis and enthesitis

Question 7

Describe HLA-B27 and spondyloarthropathies (SpA)

Answer 7

Not diagnostic of SpA
Positive in 80/95% of patients with radiographic SpA and less in non-radiographic (60%)
Risk of AS increases in relatives

Question 8

What are the stages of axial SpA?

Answer 8

Non-radiographic (back pain and sacroiliitis on MRI)
Then radiographic stage - radiographic sacroiliitis and syndesmophytes
Sometimes stay non-radiographic

Question 9

What is the ASAS classification for axial SpA?

Answer 9

In patients with more than 3 months of back pain and age of onset less than 45
Sacroiliitis on imaging plus more than 1 feature or HLA-B27 plus more than 2 features

Question 10

What are the SpA features in ASAS classification?

Answer 10

Inflammatory back pain, arthritis, enthesitis (heel), uveitis, dactylitis, psoriasis, Chron’s disease, good response to NSAIDs, HLA-B27 and elevated CRP

Question 11

What are characteristics that differentiate between radiographic and non-radiographic?

Answer 11

Radiographic - More men (3:1)
Non-radiographic - equal sex, more likely to be HLA-B27 negative and presentation less classical

Question 12

What is suggestive of sacroiliitis on MRI?

Answer 12

Bilateral changes of both sides of the joint are more suggestive

Question 13

What are some other systemic features of spondyloarthropathies (SpA)?

Answer 13

Peripheral joints - hips, shoulder and knees
Achillies tendonitis
Uveitis
Cardiac - aortic incompetence and heart block
Pulmonary - apical fibrosis
Osteoporosis and spinal fractures
Cauda equina syndrome
Secondary amyloidosis - renal
IBD

Question 14

What are some clinical subtypes of psoriatic arthritis?

Answer 14

Arthritis with DIP joint involvement
Symmetric polyarthritis
Asymmetric oligoarticular arthritis (4 joints or less)
Arthritis mutilans (melting of joints)
Predominant spondylitis

Question 15

What are some important factors of psoriatic arthritis?

Answer 15

Also characterised by dactylitis and enthesitis
Severity of joint disease does not correlate to extent of skin disease
Nail pitting seen

Question 16

What are some joints commonly affected by psoriasis arthritis?

Answer 16

Neck, shoulder, elbows, wrists, all joints of knuckles fingers and thumbs, ankles, knees, back of spine and all joints of toes

Question 17

What is the treatment for psoriatic arthritis?

Answer 17

Sulfasalazine, Methotrexate, leflunomide, Cyclosporine, Anti-TNF therapy, Anti-IL-17 and IL-23, steroids, physiotherapy, and axial disease treated similar to AS

Question 18

What is Reactive arthritis?

Answer 18

Sterile synovitis after distant infection
Disease may be systemic
Usually mono or oligoarthritic
Infections of throat, urogenital and GI
Dactylitis and enthesitis seen

Question 19

What infections can cause reactive arthritis?

Answer 19

Salmonella, shigella, yersinia, campylobacter, chlamydia, trachomatis or pneumoniae, borrelia, neisseria and streptococci

Question 20

What are some classic features of reactive arthritis - skin and mucous membrane?

Answer 20

Keratoderma blenorrhagica - classic feature rash
Scleritis and conjunctivitis
Urethritis
Iritis
Circinate balanitis

Question 21

What is Reiter’s syndrome?

Answer 21

Triad of arthritis, urethritis and conjunctivitis

Question 22

What are some prognostic signs of chronic reactive arthritis?

Answer 22

Hip/ heel pain
High ESR
Family history and HLA-B27 positive

Question 23

What is the acute treatment of reactive arthritis?

Answer 23

NSAIDs
Joint injection
Antibiotics in chlamydia infection

Question 24

What is the chronic treatment for reactive arthritis?

Answer 24

NSAIDs and DMARD - sulphasalazine and methotrexate

Question 25

What is enteropathic arthritis?

Answer 25

Commonly associated with IBD - Chron’s or UC
Can be peripheral and/ or axial disease
Enthesopathy commonly seen

Question 26

When is eneropathic arthritis rarely seen?

Answer 26

Whipple’s disease, infectious enteritis and Coeliac disease

Question 27

What is the treatment for spondyloarthropathies?

Answer 27

Physio
NSAIDs - can reduce spinal fusion
Steroids - short term or rescue
DMARDs
Biologic drugs
For enteropathic related arthritis - bowel resection may help

Question 28

What biologics can be used in spondyloarthropathies?

Answer 28

Anti-TNF, Anti-IL-17, Anti-IL12/23 and JAK inhibitors
Many licensed for skin, bowel and joint disease

Question 29

What can help differentiate inflammatory back pain?

Answer 29

Quality and quantity of morning stiffness
Stiffness improves with movement