Spondyloarthritis



What is Spondyloarthritis ?

  • It is a type of arthritis that attacks the spine and, in some people, the joints of the arms and legs.
  • It can also involve the skin, intestines and eyes. The main symptom (what you feel) in mostpatients is low back pain. This occurs most often in axial spondyloarthritis.
  • In a minority of patients, the major symptom is pain and swelling in the arms and legs. This type is known as peripheral spondyloarthritis.
  • Many people with axial spondyloarthritis progress to having some degree of spinal fusion, known as ankylosing spondylitis.

Diseases & Conditions

  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis/Reiter’s syndrome
  • Enteropathic arthritis
  • Undifferentiated: Patients with features of more than one disease who do not fit in the defined categories above

Ankylosing spondylitis (AS)

  • AS is a chronic, systemic, inflammatory disease of the joints and ligaments of the spine. Other joints may be involved.
  • This typically results in pain and stiffness in the spine.
  • The disease may be mild to severe. The bones of the spine may fuse over time causing a rigid spine.
  • Early diagnosis and treatment may help control the symptoms and reduce debility and deformity.
Who gets ankylosing spondylitis (AS)?
  • The onset is typically in late adolescence to early adulthood. It is rare for AS to begin after age 45. Ankylosing spondylitis tends to start in the teens and 20s and strikes males two to three times more often than females.
  • Family members of affected people are at higher risk, depending partly on whether they inherited the HLA-B27 gene.
  • The incidence is 1 in 1000 persons. About 90% of people with AS have the HLA B27 gene.
What causes ankylosing spondylitis (AS)?

The cause of AS is unknown although there appears to be some genetic component. AS is associated with the HLA B27 gene but it is unclear why. The gene is seen in about 8% of normal Caucasians. There are no known infectious or environmental causes. The gut organisms may play a role in causing the disease.

What are the signs and symptoms?
  • Early on, there is pain and stiffness in the buttocks and low back due to sacroiliac joint involvement.
  • Over time, the symptoms can progress up the spine to involve the low back, chest and neck. Ultimately, the bones may fuse together causing limited range of motion of the spine and limiting one’s mobility.
  • Shoulders, hips and sometimes other joints may be involved.
  • AS may affect tendons and ligaments. For example, the heel may be involved with Achilles
  • tendonitis and plantar fasciitis.
  • Since it is a systemic disease, patients can get fever and fatigue, eye or bowel inflammation, and Rarely, there can be heart or lung involvement.
  • AS is typically non lifethreatening.
  • Usually, it is a slowly progressive disease. Most people are able to work and function normally.
How is ankylosing spondylitis (AS) diagnosed?
  • The diagnosis is typically suspected by the doctor based on the signs and symptoms. The doctor will take a thorough history and do a physical examination.
  • Xrays, especially those of the sacroiliac joints and spine can be confirmatory.
  • If X-rays do not show enough changes, but the symptoms are highly suspicious, your
  • doctor might order magnetic resonance imaging, or MRI, which shows these joints better and can pick upearly involvement before an X-ray can.
  • The HLA B27 gene may be checked by a blood test, but its presence or absence does not ultimately confirm or reject the diagnosis.
How is ankylosing spondylitis (AS) treated?
  • At this time there is no known curative treatment.
  • Goals of treatment are to reduce pain and stiffness, slow progression of disease, prevent deformity, maintain posture and preserve function.
  • Exercise programs are an essential part of the treatment.
  • Patients may be referred for a formal physical therapy program. Patients with AS are givendaily exercises for stretching and strengthening, deep breathing exercises and posture exercises to avoid stooping and slumping. Most recommended are exercises that promote spinal extension and mobility.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are traditionally used to control symptoms. There are many drug treatment options. The first lines of treatment are the NSAIDs, such as naproxen,ibuprofen, meloxicam or indomethacin. No one NSAID is superior to another. Given in the correct dose andduration, these drugs give great relief for most patients.
  • Steroids, such ascortisone or prednisone, are rarely used, except for with injections to a tendon or joint. Sometimes, medications that are normally used for rheumatoidarthritis, such as sulfasalazine or methotrexate, may be used. These appear to be less helpful for the spine disease.
  • Frequent exercise is essential to maintainjoint and heart health.
  • If you smoke, try to quit. Smoking aggravates spondyloarthritis and can speed up the rate of spinal fusion
  • TNF alpha blockers (a newer class of drugs known as biologics) are very effective in treating both the spinal and peripheral joint symptoms of spondyloarthritis. TNF alpha blockers that the FDA has approved for use in patients with ankylosing spondylitis are:
    • infliximab (Remicade), which is given intravenously (by IV infusion) every 6-8 weeks at a dose of 5 mg/kg;
    • etanercept (Enbrel), given by an injection of 50 mg under the skin once weekly;
    • adalimumab (Humira), injected at a dose of 40 mg every other week under the skin;
    • golimumab (Simponi), injected at a dose of 50 mg once a month under the skin.
  • However, anti-TNF treatmentis expensive and not without side effects, including an increased risk for serious infection. Biologics can cause patients with latent tuberculosis (no symptoms) to develop an active infection.

Therefore, you and your doctor should weigh the benefits and risks when considering treatment with biologics. Those with arthritis in the knees, ankles,elbows, wrists, hands and feet should try DMARD therapy before anti-TNF treatment.

These drugs may not only help symptoms but also slow the progression of the disease. They are only given as IV’s in the doctor’s office or by self administered shots at home.

Does surgery help?

  • Surgical options are limited.
  • Total hip replacement is very useful for those with hip pain and disability due to joint destruction from cartilage loss.
  • Spinal surgery is rarely necessary, except for those with traumatic fractures (broken bones due to injury) or to correct excess flexion deformities of the neck, where the patient cannot straighten the neck.

Broader health impacts: Other problems can occur in patients with spondyloarthritis.

  • Osteoporosis which occurs in up to half of patients with ankylosing spondylitis, especially in those whose spine is fused. Osteoporosis can raise the risk of spinal fracture.
  • Inflammation of part of the eye, called uveitis, which occurs in about 40% of those with spondyloarthritis. Symptoms of uveitis include redness and pain of the eye. Steroid eye drops mostoften are effective, though severe cases may need other treatments from an ophthalmologist.
  • Inflammation of the aortic valve in the heart, which can occur over time in patients with spondylitis.
  • Psoriasis, a patchy skin disease, which if severe will need treatment by a dermatologist.
  • Intestinal inflammation, which may be so severe that it requires treatment by a gastroenterologist.

Psoriasis

What is psoriasis?
  • Psoriasis is a chronic skin disorder that produces thick, pink to red, itchy areas of skin covered with white or silvery scales.
  • The rash usually occurs on the scalp, elbows, knees, lower back and genitals, but it can appear anywhere. It can also affect the fingernails.
  • Psoriasis usually begins in early adulthood but it can start later in life. The rash can heal and come back throughout a person’s life.
  • Psoriasis is not contagious and does not spread from person to person. In most people, the rash is limited to a few patches of skin.
  • In severe cases, it can cover large areas of the body.
How does the rash start?
  • Psoriasis starts as small red bumps that grow in size, on top of which scale forms. These surface scales shed easily, but scales below them stick together.
  • When scratched, the lower scales may tear away from the skin, causing pinpoint bleeding. As the rash grows larger, “plaque” lesions can form.
What are the symptoms of psoriasis?

As well as the symptoms described above, the rash can be associated with:

  • Itching
  • Dry and cracked skin
  • Scaly scalp
  • Skin pain
  • Pitted, cracked, or crumbly nails
  • Joint pain
What are less common forms of psoriasis?
  • Inverse psoriasis Psoriasis found in skin folds. This form may present as thin pink plaques without scale.
  • Guttate psoriasis Small, red, dropshaped, scaly spots in children and young adults that often appear after a sore throat caused by a streptococcal infection.
  • Pustular psoriasis Small, pus-filled bumps appear on the usual red patches or plaques.
  • Sebopsoriasis Typically located on the face and scalp, this form is made of red bumps and plaques with greasy yellow scale. This is an overlap between psoriasis and seborrheic dermatitis.
How can I know if I have psoriasis?
  • If you have a skin rash that does not go away, contact your healthcare provider. He or she can look at the rash to see if it is psoriasis or another skin condition.
  • A small sample of skin may be taken to view under a microscope.
What causes psoriasis?
  • The cause of psoriasis is unknown. The condition tends to run in families, so it may be passed on to children by parents.
  • Psoriasis is relates to a problem of new skin cells developing too quickly. Normally, skin cells are replaced every 28 to 30 days.
  • In psoriasis, new cells grow and move to the surface of the skin every three to four days. The build up of old cells being replaced by new cells creates the hallmark silvery scales of psoriasis.
What causes psoriasis outbreaks?
  • No one knows what causes psoriasis outbreaks. How serious and how often outbreaks happen varies with each person. Outbreaks may be triggered by:
  • Skin injury (for example, cuts, scrapes or surgery)
  • Emotional stress
  • Cold, cloudy weather
  • Streptococcal and other infections
  • Certain prescription medicines (for example, lithium, and certain beta blockers)
How is psoriasis treated?
  • Your healthcare provider will select a treatment plan depending on the seriousness of the rash, where it is on your body, your age, health, and other factors.
  • For a limited disease affecting only few areas on the skin, topical creams or ointments may be all that is needed. When larger areas are involved, or joint pain indicating arthritis is suspected, additional therapy may be needed.
Common treatments include:
  • Steroid creams
  • Moisturizers (to relieve dry skin)
  • Anthralin (a medicine that slows skin cell production)
  • Coal tar (common for scalp psoriasis; may also be used with light therapy for severe cases; available in lotions, shampoos and bath solutions)
  • Vitamin D3 ointment
  • Vitamin A or “retinoid” creams.Vitamin A in foods and vitamin pills has no effect on psoriasis

Treatment for severe cases:

  • Light therapy (ultraviolet light at specific wavelengths decreases inflammation in the skin and helps to slow the production of skin cells)
  • PUVA (treatment that combines a medicine called “psoralen” with exposure to a special form of ultraviolet light)
  • Methotrexate (a medicine taken by the mouth; methotrexate can cause liver disease, so its use is limited to severe cases and is carefully watched with
  • blood tests and sometimes liver biopsies)
  • Retinoids (a special form of Vitamin Arelated
  • drugs, retinoids can cause serious side effects, including birth defects)
  • Cyclosporine (a very effective capsule reserved for severe psoriasis because it can cause high blood pressure and damage to kidneys).
  • Newer drugs for treating psoriasis include injectable immune “biologic” therapies as well as small molecule immune modulating pills. They work by blocking the body’s immune system from “kickstarting” an autoimmune disease such as psoriasis.These include anti-TNF agents like Enbrel, humira and  secukinumab (cosentyx) and ustekinumab .
Can psoriasis be cured?

Psoriasis cannot be cured, but treatment greatly reduces symptoms, even in severe cases.

Tips for improving psoriasis in addition to prescription medicines:

  • Use moisturizer.
  • Avoid using harsh soaps.
  • Apply oil or moisturizer after bathing.
  • Use a tar or salicylic acid shampoo for scale on scalp

 

Psoriatic Arthritis

What is Psoriatic Arthritis?
  • Psoriatic arthritis is a form of inflammatory arthritis
  • Up to 30 percent of people with psoriasis can develop psoriatic arthritis.
  • Both psoriasis and psoriatic arthritis are chronic autoimmune diseases – meaning, conditions in which certain cells of the body attack other cells and tissues of the body.
  • Psoriasis is most commonly seen as raised red patches or skin lesions covered with a silvery white buildup of dead skin cells, called a scale.
  • Scales can occur on any part of the body. Psoriasis is not contagious – you cannot get psoriasis from being near someone with this condition or from touching psoriatic scales.
  • There are five different types of psoriatic arthritis. The types differ by the joints involved, ranging from only affecting the hands or spine areas to a severe deforming type called arthritis mutilans.
  • Like psoriasis, psoriatic arthritis symptoms flare and subside, vary from person to person, and even change locations in the same person over time.
How is psoriatic arthritis diagnosed?
  • There is no single test to diagnose psoriatic arthritis. Doctors make the diagnosis based on a patient’s medical history, physical exam ,blood tests ,laboratorytests and MRIs and/or Xrays of the affected joints.
  • Xrays are not usually helpful in making a diagnosis in the early stages of the disease.
  • In the later stages, Xrays may show changes that are more commonly seen only in psoriatic arthritis.
  • The diagnosis of psoriatic arthritis is easier for your doctor to confirm if the psoriasis exists along with symptoms of arthritis
  • However, in as many as 15% of patients, symptoms of psoriatic arthritis appear before symptoms of psoriasis.
  • Since the disease symptoms can vary from patient to patient, it is even more important to meet with your doctor when symptoms worsen or new symptoms appear.
What are the symptoms of psoriatic arthritis?
  • The symptoms of psoriatic arthritis may be gradual and subtle in some patients; in others, they may be sudden and dramatic.
  • The most common symptoms – and you may not have all of these of psoriatic arthritis are:
  • Discomfort, stiffness, pain, throbbing, swelling, or tenderness in one or more joints
  • Reduced range of motion in joints
  • Joint stiffness and fatigue in the morning
  • Tenderness, pain, or swelling where tendons and ligaments attach to the bone (enthesitis); example: Achilles’ tendonitis
  • Inflammation of the eye (such as iritis)
  • Silver or gray scaly spots on the scalp, elbows, knees, and/or the lower spine
  • Inflammation or stiffness in the lower back, wrists, knees or ankles
  • swelling in the distal joints (small joints in the fingers and toes closest to the nail), giving these joints a sausage like Appearance
  • Pitting (small depressions) of the nails Detachment or lifting of fingernails or toenails Other tests supportive for the diagnosis
  • Positive testing for elevated sedimentation rate (indicates the presence of inflammation)
  • Positive testing for elevated C reactive protein (indicates the presence of acute inflammation)
  • A negative test for rheumatoid factor and anti-CCP( performed to rule out rheumatoid arthritis)
  • Anemia a state in which there is a decrease in hemoglobin
Who is at risk for psoriatic arthritis?
  • Psoriatic arthritis occurs most commonly in adults between the ages of 30 and 50; however, it can develop at any age.
  • Psoriatic arthritis affects men and women equally.
  • Up to 40% of people with psoriatic arthritis have a family history of skin or joint disease.
  • Children of parents with psoriasis are three times more likely to have psoriasis and are at greater risk for developing psoriatic arthritis than children born of parents without psoriasis.
  • If you do have psoriasis, let your doctor know if you are having joint pain. In as many as 85% of cases, the skin disease occurs before the joint disease.
What causes psoriatic arthritis?
  • The cause of psoriatic arthritis is unknown. Researchers suspect that it develops from a combination of genetic (heredity) and environmental factors.
  • They also think that immune system problems, infection, and physical trauma play a role in determining who will develop the disorder.
  • Psoriasis itself is not an infectious condition.
  • Recent research has shown that people with psoriatic arthritis have an increased level of tumor necrosis factor (TNF) in their joints and affected skin areas. These increased levels can overwhelm the immune system, making it unable to control the inflammation associated with psoriatic arthritis.
The approach to treatment
  • Early diagnosis and treatment can relieve pain and inflammation and help prevent progressive joint involvement and damage.
  • Without treatment, psoriatic arthritis can potentially be disabling and crippling.
  • The type of treatment will depend on how severe your symptoms are at the time of diagnosis. Some early indicators of more severe disease include onset at a young age, multiple joint involvement, and spinal involvement.
  • Good control of the skin may be valuable in the management of psoriatic arthritis.
  • In many cases, you may be seen by two different types of doctors – a rheumatologist and a dermatologist.
What are the treatment options for psoriatic arthritis?
  • The aim of treatment for psoriatic arthritis is to relieve symptoms. Treatment may include any combination of the following:
  • Choice of medications depends on disease severity, number of joints involved, and associated skin symptoms.
  • During the early stages of the disease, mild inflammation may respond to nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Cortisone injections may be used to treat ongoing inflammation in single joint.
  • However, oral steroids, if used to treat the psoriatic arthritis, can worsen the skin rash due to psoriasis worse.
  • DMARDs are used when NSAIDs fail to work and in patients with erosive disease. DMARDs that are effective in treating psoriatic arthritis include:methotrexate, sulfasalazine, cyclosporine, leflunomide and biologic agents .Sometimes combinations of these drugs may be used together.
  • The anti-malarial drug usually is avoided as it can cause a flare of psoriasis. Azathioprine

may help those with severe forms of psoriatic arthritis.

  • The biologic agents are among the most exciting drug treatments. Both DMARDS and Biologics not only do these drugs reduce the signs and symptoms of psoriatic arthritis, but they also slow down joint damage
    • Enbrel (etanercept)
    • Humira (adalimumab)
    • Remicade (inflixamab)
    • Simponi (golimumab)
    • Stelara (ustekinumab)
    • Secukinumab(cosentyx)
Other Nonmedicine Therapies

Exercise :

  • Moderate, regular exercise may relieve joint stiffness and pain caused by the swelling seen with psoriatic arthritis. Rangeofmotion and strengthening exercises specifically for you combined with low impact aerobics, may be helpful.
  • Improper exercise programs may make psoriatic arthritis worse. Before beginning any new exercise program, discuss exercise options with a doctor.
  • Heat and cold therapy: Heat and cold therapy involves switching the use of moist heat and cold therapy on affected joints. Moist heat supplied by a warm towel, hot pack, or warm bath or shower helps relax aching muscles and relieve joint pain, swelling, and soreness. Cold therapy supplied by a bag of ice can reduce swelling and relieve pain by numbing the affected joints.
  • Joint protection and energy conservation
  • Daily activities should be performed in ways that reduce excess stress and fatigue on joints. Proper body mechanics (the way you position your body during a physical task) may not only protect joints, but also conserve energy. People with psoriatic arthritis are encouraged to frequently change body position at work, at home, and during leisure activities. Maintaining good posture standing up straight and not arching your back is helpful for preserving function.

Does surgery have a role ?

  • Surgery:Most people with psoriatic arthritis will never need surgery. However, severely damaged joints may require joint replacement surgery
  • The goal of surgery is to restore function, relieve pain, improve movement, or improve the physical appearance of the affected area.

Broader health impact of psoriatic arthritis

  • The impact of psoriatic arthritis depends on the joints involved and the severity of symptoms. Fatigue and anemia are common.
  • Some psoriatic arthritis patients also experience mood changes. Treating the arthritis and reducing the levels of inflammation helps with these problems.
  • People with psoriasis are slightly more likely to develop high blood pressure, high cholesterol, obesity or diabetes.
  • Maintaining a healthy weight and treating high blood pressure and cholesterol are also important aspects of treatment. There is no cure for psoriatic arthritis.
  • Once you understand the disease and learn to predict the ways in which your body responds to the disease, you can use exercise and therapy to alleviate discomfort and reduce stress and fatigue.
  • Mental exercises as well as sharing your experiences with family, a counselor or a support group, may help you cope with the emotional stress related to changes in physical appearance and disability associated with the disorder.

Reactive arthritis (ReA)

  • Reactive arthritis is a noninfectious inflammation of one or several joints.
  • It may be selflimited,relapsing or chronic.
  • The condition sometimes followsan infection of the gastrointestinal or genitourinary system.
  • There may be other nonjointfeatures such as eye, genital tract, bowel or skin inflammation.
Who gets reactive arthritis?
  • ReA may follow an infection of the genital tract or bowel, but this is not always identified.
  • It is more common in men and Caucasians. ReA is rare after theage of 50.
  • The disease is associated with the HLA B27 gene in 50 -80%of patients.
What causes reactive arthritis?
  • The cause of ReA is unknown.
  • It is associated with the HLA B27 gene, but it is unclear why. It is also unclear why ReA is sometimes associated withinfection. (Bacterial infections of genital tract with Chlamydia or gastrointestinal tract with Shigella, Salmonella, or Campylobacter).
What are the signs and symptoms of reactive arthritis?
  • ReA may follow several weeks after a genital tract or bowel infection. The patient may have acute swelling, pain and redness in one or more joints.
  • Typically, it is more common in the lower extremity joints.
  • During the joint symptoms, one may also have noninfectiousgenital tract, skin or eye inflammation.
  • ReA patients may have tendonitis, especially of the heel. There may be spine involvement (like ankylosing spondylitis).
  • Traditionally, ReA isselflimitedto 3 to 12 months, but up to 50% may have relapsing or chronic disease. The disease is not life threatening, and most people are able to workand function normally.
How is reactive arthritis diagnosed?
  • The diagnosis is typically made by a doctor taking a thorough history and physical examination.
  • A swollen joint may be aspirated to rule out an infectionor gout. There is no specific test for the diagnosis of ReA. The HLA B27 gene may be checked by blood test in selected cases, but it is not diagnostic.
How is reactive arthritis treated?
  • At this time, there is no curative treatment. Any existing infection, if discovered, should be treated. The role of routine antibiotics is controversial.
  • Physicaltherapy, stretching and exercise are prescribed.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are given for pain and stiffness.
  • Steroid injections toinvolved tendons or joints can help relieve pain and inflammation.
  • In chronic or relapsing cases, similar treatments to rheumatoid arthritis can beconsidered to include methotrexate, sulfasalazine and the biologic antiTNFadrugs

Enteropathic arthritis

Enteropathic arthritis is peripheral joint or spine disease associated with inflammatory bowel disease (IBD), such as Crohn’s Disease or Ulcerative Colitis.

Who gets enteropathic arthritis?

Enteropathic arthritis is seen in up to 10 -20%of those with IBD. It is more common in juveniles and young adults. The male to female ratio is equal.

What causes enteropathic arthritis?

The cause is unknown.

What are the signs and symptoms of enteropathic arthritis?
  • The arthritis typically occurs after the bowel disease is well established. Rarely, the arthritis can start before IBD is diagnosed. There is pain and swellingin one or more joints. Typically, the arthritis occurs in the lower extremity joints. The arthritis may mirror the activity of the bowel disease.
  • There mayalso be spine involvement (like ankylosing spondylitis). The HLA B27 gene is seen in up to 50% with spine involvement.
  • The spondylitis (spine involvement)is less likely to correlate with the bowel disease activity.
  • Patients may have other systemic symptoms such as fever, skin or eye inflammation, and oralulcers. Enteropathic arthritis rarely causes joint destruction, deformity or significant disability.
How is enteropathic arthritis treated?
  • Like the other spondyloarthropathies, the patient needs physical therapy and exercise. Treatment of the bowel disease may help the peripheral joints but not the spine.
  • Removing the colon (colectomy) in ulcerative colitis may “cure” the arthritis.
  • One can use nonsteroidal anti-inflammatory drugs (NSAIDs),but there is a need to be aware of the bowel effects.
  • Local injection of steroids into joint(s) can be very helpful. Oral steroids can be used in more severecases.
  • In resistant cases, medications normally used to treat rheumatoid arthritis, such as methotrexate, azathioprine (Imuran®) or sulfasalazine can betried for the joints.
  • AntiTNFadrugs, like adalimumab (Humira®) and infliximab (Remicade®) have shown benefit with joint and bowel disease.