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Organizational Meeting for the AS-US Working Group Advancing Clinical Research in AS and SpA in the USA. Spondylitis Association of America 20 Years of Setting the Course. Concluding Remarks. Muhammad Asim Khan, MD, MACP, FRCP Professor of Medicine Case Western Reserve University

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Organizational Meeting for the AS-US Working GroupAdvancing Clinical Researchin AS and SpA in the USA

Spondylitis Association of America

20 Years of Setting the Course


Concluding Remarks

Muhammad Asim Khan, MD, MACP, FRCP

Professor of Medicine

Case Western Reserve University

Cleveland, Ohio, USA


The spondyloarthropathies
The Spondyloarthropathies

Ankylosing

Spondylitis

Juvenile SpA

Psoriatic

Arthritis

Undiff SpA

Reactive arthritis

Arthritis

associated with

Ulcerative colitis

Crohn’s dis


Estimates of Prevalence of

SpA in the US 1998 Report*

  • Conservative Estimates of Prevalence of SpA (AS, ReA, PsA, Enteropathic Arthritis)

  • 2.1 cases per 1,000 population among adults (individuals over 15 yrs of age): { 0.21% }(1990 population)

  • Based on studies using the disease specific criteria

*Lawrence RC, et al. Arthritis Rheum 1998; 41:778-799


Prevalence of PsA

No population-based US study


An epidemiological survey of as in tromso norway hla b27 prevalence 16
An Epidemiological Survey of AS in Tromso, Norway [HLA-B27 Prevalence 16%]

  • AS Prevalence = 1.1% to 1.4%.1

    • 4 to 6 times more common in males (males: 1.9 - 2.2% and females: 0.3 - 0.6%)

    • 6.7% of the B27(+) & 0.2% of B27(-) individuals had AS

    • 22.5% of the B27(+) subjects with chronic back pain or stiffness had AS

  • In contrast: Total prevalence of RA in Troms county (in individuals aged >20) = 0.39% - 0.47%.2

1Gran JT, Husby G, Hordvik M. Ann Rheum Dis 1985; 44: 359-67.

2 Riise et al. J Rheumatol 2000; 27: 1386-9.


Spondyloarthropathies

ESSG Criteria

7

Dougados M, et al. Arthritis Rheum. 1991 Oct;34(10):1218-1227.


Spondyloarthropathies

Amor Criteria 1990

8

Amor B, et al. Rev Rheum Mal Osteoartic. 1990;57:85-89.


Prevalence of AS & Related SpA (%)

10

Adapted with permission from Khan MA. Ann Intern Med. 2002;136:896-907.


Sacroillitis most common among the spondyloarthropathies
Sacroillitis: Most Common Among The Spondyloarthropathies

Ankylosing

Spondylitis

Juvenile SpA

Psoriatic

Arthritis

Entheitis

Sacroiliitis

Synovitis

Undiff SpA

Reactive arthritis

Reiter syndrome

Arthritis

associated with

Ulcerative colitis

Crohn’s dis



ENTHESIS

  • Compact fiber bundles region

  • Fibrocartilage, non-mineralized

  • Mineralized fibrocartilage

  • Lamellar bone

Braun, Khan, Sieper. ARD 2000; 59: 985-94


a) MRI of the SI joints

c) MRI subtraction evaluation

Enhancement of SI joints (synovial part & juxta-articular bone (‘bone edema’)

Khan MA: In: Hochberg et al. RHEUMATOLOGY, (3rd Ed.) 2003, (in press).

(Courtesy of M. Rudwaleit and J. Sieper.)

b) 5 minutes after gadolinium inj.


Khan MA: In: Hochberg et al. RHEUMATOLOGY, (3rd Ed.) 2003, (in press).


How to make an early diagnosis
How to make an early diagnosis?

Probability of AS/Axial SpA in Patients With Back Pain

Underwood & Dawson

Brit J Rheumatol 1995.

Chronic Back Pain

5%

Inflammatory Back Pain

14%

Any one of the additional clinical features:

e.g. enthesitis, positive family history, uveitis, asymmetric arthritis, positive response to NSAIDs, etc.

30-70%

Imaging = X-rays

If negative, then CT or MRI

(or HLA-B27)

95% probability

AS/Axial SpA

Courtesy Rudwaleit & Sieper

  • Khan MA. Ankylosing spondylitis: Clinical features. In: Hochberg et al (Eds). RHEUMATOLOGY, (3rd Edition). London, Mosby. 2003.


Hla b27 distribution
HLA B27 Distribution

25

24

30

16

40

19-34

40

8

50

HLA B2709

HLA B2706

0

0

0

Khan MA. Current Opin Rheumatol 1995;7:263-269.


Noncompliance the other drug problem
Noncompliance: The Other “Drug Problem”

Rates of non-compliance with arthritis

therapy ranges from 22% to 75%

Maetzel et al.

Rheumatology 2000; 39:975.


Educating the patients and their families
Educating the Patients and their Families

  • Patient education enhances therapeutic compliance

  • An active participation by the patient is needed in treatment strategies

  • These strategies will fail if patient is not committed

  • Comprehensive management strategies include not only medical but also emotional and social support

Khan MA.

Ankylosing Spondylitis: The facts. 2002, Oxford Univ Press.


The word doctor implies education more than healing
The Word Doctor implies Education more than Healing

  • Importance of appropriate posture and regular exercises

  • What kind of a bed to sleep on, and proper sleeping posture

  • What kind of chair to sit on, and ideal sitting posture

  • Advice about car driving, proper shoes, recerational sports, working postures, and working environment

Khan MA.

Ankylosing Spondylitis: The facts. 2002, Oxford University Press


The word doctor implies education more than healing cont d
The Word Doctor implies Education more than Healing, Cont’d.

  • Counselling about family & professional life

  • Risk of physical trauma and spinal fracture

  • Importance of long term drug therapy

  • Special instructions for taking the prescribed drugs & any potential untoward effects

Khan MA.

Ankylosing Spondylitis: The facts. 2002, Oxford Univ. Press.


As patient education
AS: Patient Education

  • Physicians need to know how their patients are getting their health care information

  • It is easy for unscrupulous individuals and organizations to disseminate via the internet unaccountable or deceptive information, often anonymously into the hands of unsuspecting patients

  • Patient education should include a discussion about these aspects as well

Khan MA.

Ankylosing Spondylitis: The facts. 2002, Oxford Univ Press.


As a multidisciplinary approach is warranted
AS: A Multidisciplinary Approach is Warranted

  • Need to work closely with patients and patient self-help organizations

    • to convince the health care authorities, insurance companies & other relevant organizations or institutions, the favorable long-term cost/benefit ratio of the newest is very effective although very costly therapies


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