SPa-lecture-European-University-of-Cyprus-.pptx.pdf

Seronegative Spondyloarthritis (SpA) Dimitrios A Pappas MD MPH Assistant Professor of Medicine Columbia University of Medicine Consultant for Guide-point Consultng services Board panel for Roche Hellas Instructor / lecturer for Novarts ( USA) Scientfc director for Consortum of Rheumatology Researche...

Seronegative Spondyloarthritis (SpA) Dimitrios A Pappas MD MPH Assistant Professor of Medicine Columbia University of Medicine Consultant for Guide-point Consultng services Board panel for Roche Hellas Instructor / lecturer for Novarts ( USA) Scientfc director for Consortum of Rheumatology Researchers of North America ( paid positon without direct funding from pharma) Disclosures Spondyloarthritis – traditional clinical Spondyloarthritis – traditional clinical subtype classification subtypeAnkylosing classification spondylitis (ASp) Ankylosing spondylitis (ASp) Reactive arthritis (ReA) Reactive arthritis (ReA) Juvenile spondyloarthritis (JSpA) Juvenile spondyloarthritis (JSpA) Enteropathic arthritis (ulcerative colitis, regional Enteropathic enteritis) arthritis (ulcerative colitis, regional enteritis) Psoriatic arthritis (PsA) Psoriatic arthritis (PsA) Undifferentiated spondyloarthritis (USpA) Undifferentiated spondyloarthritis (USpA) The frequency of the diseases of the spondylitis group is Thesimilar frequency of the diseases of the spondylitis group is to that of RA, affecting ~1% of the population no need to order tbodies “Seronegative” - Defnition RF and ANA are positve in 10-15% of the general healthy populaton ANCA ( atypical) may be present in enteropathic resence of RF or ANA DO NOT xclude the presence of SpA Antbodies do not play a pathogenic role Usually antbodies are not present eronegatve SpA “Seronegative” - Defnition “Spondyloarthropathy” - Defnition It doesn’t affect only the spine May affect peripheral joints oarthritis Ankylosing spondylitis Axial spondyloarthritis Ankylosing spondylitis Widespread spondylitis and sacroiliitis (ASp) Male: female =3-10:1 Widespread spondylitis and sacroiliitis Culminates in boney ankylosis of Male: female =3-10:1 spine due to new bone formation Culminates in boney ankylosis of Onset, age 10-35 with inflammatory spine due to new bone formation back pain Onset, age 10-35 with inflammatory Hip, shoulder knee arthritis in ~30% >95%of those affected are HLA-B*27 back pain Hip, shoulder knee arthritis in ~30% ce follows circumpolar distribution of HLA-B*27 Epidemiology: >95%of those affected are HLA-B*27 LA-B*27individuals arthritis - Course n and over lowly stiffness mately pinal of lumbar lordosis, buttock atrophy and Psoriasis / Psoriatic Arthritis Psoriasis / Psoriatic Arthritis Psoriasis: autoimmune skin disease strongly associated with HLAC*06characterized bystrongly retardation in kertinocyte differentiation Psoriasis: autoimmune skin disease associated with HLAinduced by cytokinesinreleased from activated T cells C*06characterized by retardation kertinocyte differentiation induced by cytokines released from activated T cells Conventional paradigm Conventional paradigm Psoriatic arthritis Psoriasis Onset age 15-30 yrsPsoriatic arthritis Psoriasis Onset age 15-30 yrs Prevalence ~3% common! Prevalence ~3% common! ~15% no 10-20% prior ~15% no 10-20% 0-20+ years psoriasis prior between Ps & PsA 0-20+ years psoriasis between Ps & PsA Implies PsA is a subset of and progresses from the common of psoriasis, but this is incorrect Implies PsA isform a subset of and progresses from the common asis / Psoriatic Arthritis oriasis: autoimmune skin disease strongly associated with HLA06characterized by retardation in kertinocyte differentiation uced by cytokines released from activated T cells entional paradigm Psoriasis Onset age 15-30 yrs Prevalence ~3% common! 10-20% 0-20+ years between Ps & PsA Psoriatic arthritis ~15% no prior psoriasis lies PsA is a subset of and progresses from the common m of psoriasis, but this is incorrect Always look for hidden psoriasis Reactive arthritis Reactive arthritis These features are frequently absent Urine and stool sterile by the tme the arthrits manifests No need for antbiotcs ( possible excepton the chlamydial related ReA) Enteropathic arthritis - Clues Think in any patent with arthrits AND symptoms from the intestne no symptoms from the intestne but evidence of malabsorpton SpA with HLAb27 negatve Terminal ileum has to be accessed during endoscopy In a patent with known enteropathic arthrits fare of peripheral joints usually means that the intestnal disease is not controlled Extra-articular features and comorbidities Therapy for AS and undiferentiated SpA  Physical therapy crucial  NSAIDs the frst line  Have disease modifying propertes  TNF inhibitors and other biologics (ant IL-17 for AS, ant-IL12/23 & Abatacept for PsA), JAK inhibitors  In patents who don’t respond to NSAIDs or have increased levels of infammaton  Not clear if they have disease modifying propertess Prevention /Management of comorbidities CVD: at least follow guidelines for general populaton Osteoporosis Order DEXA of femoral neck L spine syndesmophytes may falsely increase BMD Infectons Vaccinate patents ( fu , pneumonia, HZ) regardless of ages Prednisone up to 10-15 mg does not seem to interfere with vaccinatons for fu and pneumonia May skip one dose of biologic agent ? Be more conservatve with HZ vaccinaton and steroids Do not vaccinate with live HZ vaccine patents on biologics – start a biologic 4 weeks afer Malignancies Age appropriate screening May have prognostc value Order when the pretest probability is high ( infammatory back pain) BUT: Present in 10 % of the general populaton 90% of AS patents are HLA B27(+) AS affects HLA B27 (+) have 50 tmes more risk compared to HLAB27 (-) Increases the likelihood BUT Its NOT diagnostc What’s the deal with HLA-B27 What’s the deal with infammatory markers ESR/CRP is not always increased Only in 50 % More frequently increased in reA Increased infammatory markers may predict favorable response to therapy with biologic agents Is sacroiliitis always due to SpA? Is sacroiliitis always due to SpA?