ANKYLOSING SPONDYLITIS

INVESTIGATION & TREATMENT MODALITIES

EVERY PATIENT SHOULD BE CAREFULLY EVALUATED AND INDIVIDUALIZED ,IN ORDER TO PROVIDE HIM THE BEST TREATMENT FOR A BETTER OUTCOME.

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ANKYLOSING SPONDYLITIS

THE PATIENT SHOULD BE EXPLAINED IN DETAIL ABOUT HIS CONDITION AND THE POSSIBLE OUTCOME AND COMPLICATIONS, AND THAT THE TREATMENT IS ONLY DIRECTED TOWARDS IMPROVING THE QUALITY OF LIFE.

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MANAGING A CASE OF ANKYLOSING SPONDYLITIS IS A TEAMWORK COMPRISING OF :

ORTHOPAEDISTS RHEUMATOLOGISTS PHYSICIANS PHYSIOTHERAPISTS PARENTS

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TEAM WORK

RECOGNITION OF A FULL BLOWN CASE IS NOT DIFFICULT

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DIAGNOSIS

THE NEED, IS OF A EARLY DIAGNOSIS OF THE DISEASE ,WHICH WOULD HELP IN A BETTER PROGNOSIS AND THIS HAS BEEN MET BY THE TWO GROUPS NAMELY:

THE ROME CRITERIA (1963)

THE NEW YORK CRITERIA (1968)

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DIAGNOSIS

ACCORDING TO THIS ,AS IS DIAGNOSED IF B/L SACROILIITIS IS SEEN ALONG WITH ONE OF THE FOLLOWING.

a) LBA & STIFFNESS OF 3 MONTHS DURATION NOT RELIEVED BY REST

b) PAIN AND STIFFNESS IN THE THORACIC SPINE

c) LIMITED LUMBAR SPINAL MOVEMENTd) LIMITED CHEST EXPANSIONe) HISTORY OR EVIDENCE OF IRITIS OR ITS

SEQUELAE

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THE ROME CRITERIA

CLINICAL CRITERIA:

a) LIMITATION OF LUMBOSACRAL MOVEMENT IN THREE PLANES

b) HISTORY OF PRESENCE OF PAIN AT DL JUNCTION WITH OR WITHOUT LUMBAR SPINE PAIN

c) LIMITED CHEST EXPANSION OF 2.5CM OR LESS AT 4TH INTERCOSTAL SPACE.

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THE NEW YORK CRITERIA

RADIOLOGICAL CRITERIA BASED ON SACROILIAC JOINT RADIOGRAPHS

GR 0 : NORMAL GR 1: POSSIBLY NORMAL(minimal sclerosis) GR 2: DEFINITE MARGINAL SCLEROSIS GR 3: DEFINITE EROSION AND SCLEROSIS GR 4: COMPLETE OBLITERATION AND

ANKYLOSIS

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THE NEW YORK CRITERIA

DEFINITE AS:

GR 3/4 BL SACROILIITIS WITH ATLEAST ONE CLINICAL CRITERIA

OR

GR 3 / 4 UL SACROILITIS WITH CLINICAL CRITERION 1

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THE NEW YORK CRITERIA

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Disease Activity Assessment

Index Metric

BASFI Disability level

BASDAI Disease activity level

ASAS - IC Composite sum of disease activity

BASFI = Bath Ankylosing Spondylitis Functional IndexBASDAI = Bath Ankylosing Spondylitis Disease Activity IndexASAS - IC = ASsessment in Ankylosing Spondylitis Improvement Criteria

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Bath Ankylosing Spondylitis Functional Index (BASFI)

Visual analog scale (VAS) – 10 cm Mean score of 10 questions Questions level of functional disability, including:

◦ Ability to bend at the waist and perform tasks◦ Looking over your shoulder without turning your body◦ Standing unsupported for 10 minutes without discomfort◦ Rising from a seated position without the use of an aid◦ Exercising and performing strenuous activity◦ Performing daily activities of living◦ Climbing 12 to 15 steps without aid

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Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)

A self-administered instrument (using 10-cm horizontal visual analog scales) that comprises 6 questions:

Over the last one week, how would you describe the overall level of:◦ Fatigue/tiredness ◦ AS spinal (back, neck) or hip pain◦ Pain/swelling in joints other than above ◦ Level of discomfort from tender areas ◦ Morning stiffness from the time you awake◦ How long does morning stiffness last?

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Modified New York Criteria for the Diagnosis of AS

Clinical Criteria◦ Low back pain, > 3

months, improved by exercise, not relieved by rest

◦ Limitation of lumbar spine motion, sagittal and frontal planes

◦ Limitation of chest expansion relative to normal values for age and sex

• Radiologic Criteria– Sacroiliitis grade 2

bilaterally or grade 3 – 4 unilaterally

• Grading– Definite AS if radiologic

criterion present plus at least one clinical criteria

– Probable AS if:• Three clinical criterion• Radiologic criterion

present, but no signs or symptoms satisfy clinical criteria

RADIOLOGICAL

LAB INVESTIGATONS

OTHER INVESTIGATIONS

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INVESTIGATIONS

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SACROILIAC JOINTS

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HIP JOINTS

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CERVICAL SPINE

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LUMBAR SPINE

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DORSO LUMBAR JUNCTION

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MRI

50 % HAVE RAISED SERUM ALKALINE PHOSPHATASE LEVELS

MANY HAVE RAISED SERUM PHOSPHOKINASE

ESR IS ELEVATED

HB IS LOW. TLC RAISED.CRP RAISED

NORMOCYTIC NORMOCHROMIC ANAEMIA

HLA B27 IS POSITIVE IN AROUND 90% OF CASES AND HAS A STRONG CORROBORATIVE VALUE IN THE DIAGNOSIS

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LAB INVESTIGATIONS

TO RULE OUT EXTRA ARTICULAR MANIFESTATIONS SUCH AS

a) UVEITIS , IRIDOCYCLITISb) INFLAMMATORY BOWEL DISEASEc) AORTIC INCOMPETENCE AND CONDUCTION

DEFECTSd) RESTRICTIVE LUNG DISEASE,PULMONARY

INFECTIONS

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OTHER INVESTIGATIONS

DRUG THERAPY

PHYSICAL THERAPY

SURGERY

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TREATMENT MODALITIES

IT IS TARGETED :

a) GIVING SYMPTOMATIC RELIEF TO THE PATIENT.

b) TO PRODUCE IMMUNOSUPPRESION.

c) SLOW DOWN THE DISEASE PROGRESS.

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DRUG THERAPY : MAINSTAY

TO RELIEVE PAIN AND INFLAMMATION :N S A I D s : Ibuprofen,Phenylbutazone, Indomethacin, Diclofenac,Naproxen,Celecoxib.

Opiod analgesics in extended release formulations for pts having chronic pain

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DRUG THERAPY

DMARD S SUCH AS cyclosporin, methotrexate, sulfasalazine

CORTICOSTEROIDS ARE USED TO REDUCE THE IMMUNE RESPONSE AND PRODUCING IMMUNOSUPRESSION

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DRUG THERAPY

MOST PROMISING AGENTS

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T N F α ANTAGONISTS

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Pathogenesis of Joint Destruction

Bone Erosions

Macrophages

Endothelium

Synoviocytes

­ Proinflammatory cytokines­ Chemokines

­ Adhesion molecules

­ Metalloproteinase synthesis

ArticularCartilage

Degradation

Increased Cell Infiltration

Increased Inflammation

Osteoclast progenitors

­­ RANKL expression

TNF

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Appropriate Patients for Anti-TNF Therapy

Active disease for 4 weeks◦ BASDAI > 4 at two times, 1 month apart

Treatment Failures◦ All types AS – lack of response/intolerability > 2

NSAIDs for 3 months

◦ Patients with peripheral arthritis – lack of response/intolerability to > 1 DMARD, sulfasalazine preferred

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Anti-TNF Agents Etanercept

◦ Dose: 50 mg SC per week as two 25 mg injections administered on same day or 3 to 4 days apart

Infliximab◦ Dose: 5 mg/kg IV at week 0, 2, and 6 and every 6

to 8 weeks thereafter

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Etanercept Vs. Infliximab:Pharmacologic Characteristics

Etanercept Infliximab

Mechanism of TNF inhibition

“Decoy” receptor for TNF

Binds to TNF and inhibits it from binding with TNF receptor

Terminal half-life 4.25 +/- 1.25 days (mean+/- SD)

8 to 9.5 days (median values)

In vitro lysis of cells expressing transmembrane TNF

No Yes

Mode of administration Subcutaneous IV infusion (over 2 to 3 hours)

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AS Treatment Algorithm:Patients with Axial AS

Alternative Options• Pamidronate• Thalidomide

*Only biologic approved for treatment of AS in US and Europe†Approved in Europe only for treatment of ASThis treatment algorithm contains unlabeled use of infliximab, pamidronate and thalidomide.

Anti-TNF agents• Etanercept 50 mg SC per week as two 25 mg injections in the

same day or 3-4 days apart*• Infliximab 5 mg/kg at 0, 2, and 6 weeks and every 6 to 8 weeks

thereafter†

• Contraindicated in patients with infections, tuberculosis, multiple sclerosis, lupus, malignancy, and pregnancy/lactation

Initiate physical therapy plan with long-term exercise program to accompanypharmacologic intervention• Emphasize posture, range of motion,

and strengthening

NSAIDs or Selective COX-2 inhibitors• Efficacy and safety comparable between non-selective agents• Selective COX-2 efficacy comparable, better safety profile, higher

cost that non-selective NSAIDs

Failure of at least two different NSAIDs/selective COX-2 inhibitorsfor minimum of 3 months

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Contraindications for Anti-TNF Therapy Current or recurrent infections Tuberculosis Multiple sclerosis Lupus Malignancy Pregnant or lactating

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Monitoring and Discontinuing Treatment With Anti-TNF Agents ASAS core set of outcome parameters to

monitor patients◦ Physical function, pain, spinal mobility, patient’s

global assessment, stiffness, peripheral joints and entheses, acute phase reactant, fatigue

Assess at 6 to 8 weeks and discontinue patients who do not meet response criteria◦ BASDAI: Reduction of 2 units and◦ Physician Global Assessment > 1

AIM: TO MAINTAIN JOINT MOVEMENT AND TO BUILD UP MUSCLES THAT OPPOSE THE DIRECTION OF DEFORMITIES I.E EXTENSORS

IT SHOULD BE STARTED ALONG WITH THE DRUG THERAPY FOR BETTER OUTCOME OR AS SOON AS THE PT HAS RELIEF FROM PAIN.

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PHYSICAL THERAPY

SWIMMING BADMINTON JOGGING YOGA DEEP BREATHING EXERCISES PRONE LYING MODIFICATION OF WORK

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PHYSICAL THERAPY

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IN LATE CASES, TRACTION APPICATION IS USEFUL

FOR LOWER LIMBS : TO OVER COME FIXED FLEXION DEFORMITIES OF THE HIP AND KNEE AND TO RELIEVE SPASM.

FOR CERVICAL SPINE TO RELIEVE PAIN AND SPASM

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PHYSICAL THERAPY

SEVERE DEFORMITY ( KYPHOSIS) DEFORMITIES OF THE HIP AND KNEE BREATHING AND VISUAL DIFFICULTIES DANGER TO THE GREAT VESSELS AND THE

SPINAL CORD ALONG WITH THE NERVE TRUNKS

COSMETIC REASONS.

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SURGERY : INDICATIONS

OSTEOTOMIES OF THE LUMBAR SPINE : 1. SMITH PETERSON OSTEOTOMY

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SURGERY

2) . PEDICLE SUBTRACTION OSTEOTOMY OF THOMASEN

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3) EGGSHELL OSTEOTOMY

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4) TRANSPEDICULAR DECANCELATION CLOSED WEDGE OSTEOTOMY

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INDICATIONS: TO ELEVATE THE CHIN FROM THE STERNUM. IMPROVEING THE APPEARANCE,THE

GAZE,THT ABILITY TO EAT. TO PREVENT ATLANTO AXIAL SUBLUXATION TO RELIEVE THE OESOPHAGEAL AND

TRACHIAL DISTORTION TO RELIEVE TRACTION ON THE CERVICAL

NERVE ROOTS.

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OSTEOTOMIES OF THE CERVICAL SPINE

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OSTEOTOMIES OF THE CERVICAL SPINE

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TOTAL HIP REPLACEMENT

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THANK YOU