It is so heartwarming and inspiring to see so many of us with AS take the challenge to bring awareness to this disease. Thank you Jane Atkinson!
Another feature of ankylosing spondylitis is a peripheral arthritis, which can occur in up to 40 per cent of patients. In some cases, the peripheral arthritis will actually occur prior to the spondylitis. The oligoarticular, inflammatory, asymmetrical pattern of involvement that strikes the lower limbs is typical. However, evidence of sacroiliitis or spondylitis would be required to make the diagnosis of ankylosing spondylitis.
Another feature is entheseopathy — inflammation at the site of insertion of a ligament or tendon to the bone — which can occur with any of the spondyloarthropathies. The most common sites tend to be the plantar fascia and Achilles tendon, though it can be seen anywhere in the body. In most rheumatic diseases, it is useful to look for extra-articular features, although they are often not present initially. In any inflammatory arthritis, patients will complain of constitutional symptoms, such as fatigue and malaise.
Reactive arthritis was first described by Hans Reiter. It has since changed its name to HLA B27 gene-associated reactive arthritis. Typically, the patient presents with an acute onset of joint pain, three weeks after the infection. This can vary from being relatively mild joint pain to quite severe inflammatory arthritis, with a lot of pain and swelling. The duration is variable: from a week to more than one month and the majority of patients will have recurrent episodes. Up to 30 per cent can develop a chronic, erosive arthropathy. These patients are treated with the many of the agents used to treat rheumatoid arthritis. There can be spondylitis in these patients and unlike ankylosing spondylitis, the spondylitis can occur anywhere in the spine.
When a history is taken, there may be an absence of GI symptoms, genito-urinary symptoms, empiric infection or history of sexually-transmitted disease. However, it is estimated that 25 per cent of patients have reactive arthritis without providing any history of the preceding infectious episode.
Enthesopathies can present. Dactylitis, or ‘sausage digit’, is inflammation of an entire finger or toe. When this is seen, it is suggestive of either reactive arthritis or psoriatic arthritis.
Extra-articular manifestations can be helpful in establishing a diagnosis. Up to 25 per cent of patients will have conjunctivitis and 50 per cent will have mucocutaneous involvement, with either oral or genital ulcers. Circinate balanitis is very characteristic of reactive arthritis.
Psoriatic arthritis is an inflammatory arthritis that occurs in patients with psoriasis and five categories have been described, but there can be overlaps. In most patients there will be two or more patterns simultaneously occurring. Sometimes the arthritis will precede the psoriasis and sometimes the psoriasis will only be apparent in the scalp or the anal cleft.
Dr Mongey outlined the approach for differentiating psoriatic arthritis patients from rheumatoid arthritis cases, in the absence of x-ray changes.
When rheumatoid factor (RF) is positive and anti-cyclic citrullinated peptide (anti-CCP) antibody is positive, this is suggestive of rheumatoid arthritis in psoriasis patients. If these are not positive, the condition is generally called psoriatic arthritis.
There is a very characteristic involvement of the distal interphalangeal (Dip) joints with the nail changes in some patients. Arthritis mutilans (‘opera glass hands’) involves telescoping of the digits and is seen in severe rheumatoid or psoriatic arthritis. This is due to bone resorption.
Rheumatoid arthritis can be aggressive and lead to deformities and erosive changes. There can be joint space narrowing as a result of cartilage destruction. In psoriatic arthritis there is also resorption of the bone, which appears to cause widening the joint space — which, however, is not possible. This is referred to as ‘pseudo-widening’ and it is very diagnostic of psoriatic arthritis. Spondylitis and sacroiliitis (among 20 to 40 per cent of patients) can also be manifestations of psoriatic arthritis.
Enteropathic arthritis is associated with inflammatory bowel disease — either Crohn’s (among 20 per cent of patients) or ulcerative colitis (among 10 per cent of patients). There is a typical presentation: an inflammatory, oligoarticular, asymmetrical pattern of involvement. It generally has a good prognosis and tends to be non-erosive and self-limiting. This form of arthritis closely reflects the activity of the bowel disease. Generally, if the bowel disease can be controlled, the arthritis will tend to also improve. It is also seen more frequently in patients with colonic — rather than small bowel — involvement of their Crohn’s. There can also be spondylitis as part of the enteropathic arthritis. Unlike peripheral arthritis, this tends to have no relationship to the underlying inflammatory bowel disease, in terms of either onset or disease activity. There is an associated HLA B27 gene.
In terms of management, physiotherapy is always recommended, particularly for ankylosing spondylitis. Non-steroidal anti-inflammatories (NSAIDs) are useful for inflammatory arthropathy and these are generally given at full dose. Two weeks of therapy is recommended to determine whether the patient is going to respond. Some gastroenterologists do not favour putting inflammatory bowel disease patients on NSAIDs. Intra-articular steroids might be considered, particularly when there are one or even two joints involved. Oral steroids might also be used.
Where the patient has more progressive disease, disease-modifying agents — or possibly TNF-alpha agents — should be considered. Sulphasalazine has been shown to be useful in peripheral arthritis associated with ankylosing spondylitis but it has not been shown to be of value in the spondylitis itself.
Sulphasalazine has also been useful in psoriatic arthritis, inflammatory bowel-related arthritis and in reducing the symptoms of reactive arthritis.
Alternative therapy after MTX or anti-TNF
“The standard initial drugs include methotrexate and anti-TNFs. Abatacept, which belongs to the biologic class of drugs, is given by infusion,” said Dr Bryan Whelan, Consultant Rheumatologist, Northwestern Rheumatology Unit, Our Lady’s Hospital, Manorhamilton, Co Leitrim, commenting on the treatments for rheumatoid arthritis (RA).
Dr Whelan has participated in the multi-national Abatacept in Routine Clinical Practice (ACTION) trial, which is an ongoing, non-interventional study of abatacept-treated RA patients with inadequate response to MTX or anti-TNF therapy, in Europe and Canada. Abatacept is licensed for rheumatoid arthritis and the trial was initiated in 2008.
Drug budgets limit the use of all biologics. “Abatacept has been on the market in Ireland for more than five years. The evidence for its use is as compelling as for any of the other treatments and it is no more expensive than the other biologic drugs,” said Dr Whelan.
Abatacept is in a drug class called selective co-stimulation modulators (immunomodulators). T-cell co-stimulation is believed to be crucial in orchestrating immune responses that lead to inflammation and destruction in RA. Abatacept is a co-stimulatory inhibitor for treatment of rheumatoid arthritis and cytotoxic T lymphocyte antigen (CTLA) is a stimulator of T-cell inhibitory signals. T-cell activation requires a co-stimulatory factor and CTLA is one of the agents that downregulates that co-stimulatory factor.
Abatacept is a soluble fusion protein consisting of the extracellular domain of human CTLA-4 (a naturally-occurring ‘switch off’ of inflammation) linked to the modified Fc domain of human IgG1. It binds to CD80/CD86 on antigen-presenting cells. In the ACTION real-world study, patients receiving 12 months of treatment with abatacept showed improved disease activity and a high retention rate, regardless of line of treatment, with a trend towards better results in biologic-naïve patients.
Categories: Ankylosing spondylitis