Ankylosing spondylitis: Difference between revisions

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==Background==
==Background==
*Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial skeleton with variable involvement of other joints or even nonarticular structures.
*Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial skeleton with variable involvement of other joints or even nonarticular structures
* Ankylosing spondylitis is three times more common in males than females. It is usually diagnosed in young adults between the ages of 20 and 30 years.
*3x more common in males than females
* Often associated with other autoimmune disorders. About 90% of people with AS express the HLA-B27 genotype.
*Typically diagnosed in young adults between the ages of 20 and 30 yrs
*Often associated with other autoimmune disorders
*90% of people with AS express the HLA-B27 genotype


==Clinical Features==
==Clinical Features==
* Spinal pain, particularly in the lower back, is usually the first and most common symptom of AS.
*Spinal pain, particularly in the lower back, is usually the first and most common symptom of AS
**Begins in early adulthood (before 45 years of age)
**Begins in early adulthood (before 45 yrs)
**Has a gradual onset
**Has a gradual onset
**Lasts longer than three months
**Lasts longer than three months
**Is worse after rest (for example, in the morning) but improves with activity
**Is worse after rest (for example, in the morning) but improves with activity
**Can cause morning stiffness lasting more than 30 minutes
**Can cause morning stiffness lasting more than 30 minutes
* Fatigue
*Fatigue
* Can also be associated with anterior uvetitis, bowel ulcers and spinal fractures are 4 times more common in patients with AS <ref> Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. European Spine Journal. 2009;18(2):145–156 </ref>
*Can also be associated with anterior uvetitis, bowel ulcers and spinal fractures are 4 times more common in patients with AS <ref> Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. European Spine Journal. 2009;18(2):145–156 </ref>


==Differential Diagnosis==
==Differential Diagnosis==
{{Lower back pain DDX}}
{{Lower back pain DDX}}
==Diagnosis==
==Diagnosis==
*There is no direct test for AS
*There is no direct test for AS
* ESR, CRP can be elevated but not sensitive or specific for AS
*ESR, CRP can be elevated but not sensitive or specific
* Xray lumbar/sacroiliac: The earliest changes in the sacroiliac joints shows erosions and sclerosis.
*Xray lumbar/sacroiliac: The earliest changes in the sacroiliac joints shows erosions and sclerosis
**Progression of the erosions leads to pseudo widening of the joint space and bony ankylosis AKA "Bamboo Spine." Often X-ray findings lag about 10 years from initial progression of disease. [[File:5269907670e86d9b415221efa30bf166.jpg|200px|thumb|right|"bamboo spine"]]
**Progression of erosions leads to pseudo widening of the joint space and bony ankylosis AKA "Bamboo Spine"  
* CBC
Often X-ray findings lag about 10 years from initial progression of disease [[File:5269907670e86d9b415221efa30bf166.jpg|200px|thumb|right|"bamboo spine"]]
*CBC
*Chem 10
*Chem 10
* UA
*UA
* Genetic testing for HLA B27 ( > 90% of people with AS have this gene, though by it's self is not specific)
*Genetic testing for HLA B27 ( > 90% of people with AS have this gene, though by it's self is not specific)
 
==Management==
==Management==
*There is no cure for AS, although treatments and medications can reduce symptoms and pain
*There is no cure for AS, although treatments and medications can reduce symptoms and pain
* Exercise and posture training should be part of the treatment program for everyone with AS
*Exercise and posture training should be part of the treatment program for everyone with AS
* NSAIDS
*NSAIDS
* Sulfasalazine can be used in people with peripheral arthritis. For axial involvement, evidence does not support sulfasalazine <ref>Chen J, Lin S, Liu C. Sulfasalazine for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD004800. DOI: 10.1002/14651858.CD004800.pub3.</ref>.  
*Sulfasalazine can be used in people with peripheral arthritis, but for axial involvement, evidence does not support it <ref>Chen J, Lin S, Liu C. Sulfasalazine for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD004800. DOI: 10.1002/14651858.CD004800.pub3.</ref>.  
* Lack of evidence for methotrexate <ref>Chen J, Veras MMS, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004524. DOI: 10.1002/14651858.CD004524.pub4.</ref> or steroids.  
*Lack of evidence for methotrexate <ref>Chen J, Veras MMS, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004524. DOI: 10.1002/14651858.CD004524.pub4.</ref> or steroids.  
* Tumor necrosis factor-alpha blockers, such as the biologics etanercept, infliximab, golimumab and adalimumab, have shown good short-term effectiveness in the form of profound and sustained reduction in all clinical and laboratory measures of disease activity. Though long term management is currently being studied.
*Tumor necrosis factor-alpha blockers, such as the biologics etanercept, infliximab, golimumab and adalimumab, provide good short-term effectiveness though long term management is currently being studied


==Disposition==
==Disposition==
* Often diagnosis will not be made in ER but if made in ER often can be discharged home with PMD F/U or Close Rheumatology f/u
*Often diagnosis will not be made in ED but if made in ED often can be discharged home with PMD f/u or rheumatology f/u
 
==See Also==
==See Also==
*Arthritis


==External Links==
==External Links==

Revision as of 15:20, 1 November 2015

Background

  • Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial skeleton with variable involvement of other joints or even nonarticular structures
  • 3x more common in males than females
  • Typically diagnosed in young adults between the ages of 20 and 30 yrs
  • Often associated with other autoimmune disorders
  • 90% of people with AS express the HLA-B27 genotype

Clinical Features

  • Spinal pain, particularly in the lower back, is usually the first and most common symptom of AS
    • Begins in early adulthood (before 45 yrs)
    • Has a gradual onset
    • Lasts longer than three months
    • Is worse after rest (for example, in the morning) but improves with activity
    • Can cause morning stiffness lasting more than 30 minutes
  • Fatigue
  • Can also be associated with anterior uvetitis, bowel ulcers and spinal fractures are 4 times more common in patients with AS [1]

Differential Diagnosis

Lower Back Pain

Diagnosis

  • There is no direct test for AS
  • ESR, CRP can be elevated but not sensitive or specific
  • Xray lumbar/sacroiliac: The earliest changes in the sacroiliac joints shows erosions and sclerosis
    • Progression of erosions leads to pseudo widening of the joint space and bony ankylosis AKA "Bamboo Spine"

Often X-ray findings lag about 10 years from initial progression of disease

"bamboo spine"
  • CBC
  • Chem 10
  • UA
  • Genetic testing for HLA B27 ( > 90% of people with AS have this gene, though by it's self is not specific)

Management

  • There is no cure for AS, although treatments and medications can reduce symptoms and pain
  • Exercise and posture training should be part of the treatment program for everyone with AS
  • NSAIDS
  • Sulfasalazine can be used in people with peripheral arthritis, but for axial involvement, evidence does not support it [2].
  • Lack of evidence for methotrexate [3] or steroids.
  • Tumor necrosis factor-alpha blockers, such as the biologics etanercept, infliximab, golimumab and adalimumab, provide good short-term effectiveness though long term management is currently being studied

Disposition

  • Often diagnosis will not be made in ED but if made in ED often can be discharged home with PMD f/u or rheumatology f/u

See Also

  • Arthritis

External Links

References

  1. Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. European Spine Journal. 2009;18(2):145–156
  2. Chen J, Lin S, Liu C. Sulfasalazine for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD004800. DOI: 10.1002/14651858.CD004800.pub3.
  3. Chen J, Veras MMS, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004524. DOI: 10.1002/14651858.CD004524.pub4.