ArticleLiterature Review

Medical and surgical treatment of seronegative spondyloarthropathy

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Ankylosing spondylitis (AS) is a chronic rheumatic disease of the axial skeleton (spine and sacroiliac joints). Only nonsteroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor (TNF) α inhibitors have currently been shown as effective for the treatment of signs and symptoms of active AS with predominant axial involvement. In contrast to rheumatoid arthritis (RA), disease-modifying anti-rheumatic drugs (DMARDs) play only a minor role in the management of AS and only in cases with peripheral joint involvement. Herein, this review describes the pharmacological and nonpharmacological management of AS, based on recent international recommendations for the management of AS by the Assessment of Spondyloarthritis (ASAS) group. Despite the overall demonstrated efficacy of currently available treatments for AS, up to 40% of treated patients do not achieve an acceptable clinical improvement during therapy. Therefore, this article also reviews the evidence regarding the potential role for new agents targeting B-cells, T-cells, interleukin (IL)-1, IL-6, IL-17, and IL-12/23 in patients with AS.
Purpose: To evaluate the efficacy and specific properties of MR imaging-guided corticosteroid infiltration of the sacroiliac (SI) joints in the treatment of therapy-refractory sacroiliitis in patients with ankylosing spondylitis. Materials and Methods: In this study, 26 patients were prospectively included. Inclusion criteria were AS with therapy refractory acute sacroiliitis and inflammatory back pain ≥ 6 months. The intervention was performed using an open low-field MR-scanner. Inflammatory back pain was assessed on a visual analog scale (VAS). Success of the therapy was defined as an absolute reduction of the VAS score < 5, a relative reduction of the VAS score ≥ 35 % and persisting improvement ≥ 2 months. The grade of sacroiliitis was documented using high-field MR imaging. Variables were compared using McNemar test and Wilcoxon test. The mean remission time was calculated using a Kaplan-Meier analysis. A p-value < 0.05 was considered statistically significant. Results: The intervention was technically successfully performed in all patients. Following MR imaging-guided corticosteroid infiltration of the SI joints, the VAS score improved from 8 (5 -10) points to 4.5 (0 - 8) points (-44%) in all patients (n = 26), which was statistically significant (p< 0.001). Of 26 patients, 22 (85%) fulfilled the predefined criteria for successful therapy. This group had a statistically significant (p < 0.01) improvement of the VAS score from 8 (6-10) to 3 (0-5) (-63%). Improvement was seen after 7 (1 - 30) days. There was a marked reduction of the subchondral bone marrow edema (-38%). The mean remission time was 12 (4-18) months. Conclusion: MR imaging-guided corticosteroid infiltration of the SI joints proved to be an effective therapy of inflammatory back pain in patients with therapy refractory AS. With the ability of multiplanar imaging, precise localization of the bone marrow edema and the lack of ionizing radiation, interventional MR imaging currently represents the superior method for the treatment of the predominantly young patient group presenting with ankylosing spondylitis. Owing to short intervention times, open MR-scanners are ideally suited for MR imaging-guided infiltration of the SI joints.
The end of this century and the dawn of the new millennium are near, and we still don't fully understand the mechanism behind the remarkable association of HLA-B27 with spondy-loarthropathies, although it has been known for more than a quarter of a century. However, there has been a slow but steady progress in the field of spondyloarthropathies. Not all alleles that encode for the HLA-B27 serologic specificity are associated with susceptibility to develop a spondyloarthropathy. The number of known subtypes of HLA-B27 continue to grow; the latest three additions are HLA-B*2713, HLA-B*2714, and HLA-B*2715. It is becoming increasingly clear that the observed synovial and cartilage changes in spondyloarthropathies are mainly the result of an entheseal- rather than a synovial-based pathology, because the initial or primary inflammatory response is located at the enthesis, whereas synovitis is most likely triggered secondarily by locally released cytokines at the adjacent sites in the joint cavity. But we still don't know how ankylosis relates to HLA-B27. The conditions favoring the development of HIV-associated spondyloarthropathy are becoming less of a problem in North America, but this is not the case in some of the other regions of the world, such as Sub-Saharan Africa.
Ankylosing spondylitis is the prototype of an interrelated group of disorders termed spondyloarthropathies, which include reactive arthritis, psoriatic arthritis, and rheumatic disorders associated with inflammatory bowel disease. It can be difficult to differentiate between these disorders because they may occur simultaneously or sequentially. In addition, some of the clinical characteristics of these diseases, such as enthesiopathy and eye involvement, are similar no matter what the diagnosis. The monitoring, diagnosis, and treatment of these diseases are related more to their clinical presentation than to the precise diagnosis.
Better understanding of the etiopathogenic mechanisms and increasing recognition of the natural course of the spondyloarthropathies are leading to a more rational therapeutic approach to several of the disorders included within this large group of arthritides. Our traditional therapeutic approach to these conditions is being challenged, and a more aggressive therapeutic regimen is being advocated in a manner not too much different from that advocated for the treatment of rheumatoid arthritis. Combination therapy with either methotrexate and sulfasalazine or methotrexate and cyclosporine is being used more often and earlier, particularly in psoriatic arthritis. An issue, however, that remains unresolved is the proper use of antibiotic therapy.
This questionnaire survey of 71 patients with ankylosing spondylitis (members of the National Ankylosing Spondylitis Society of the UK) revealed that a substantial proportion of patients were apparently not told of several aspects of their illness by their doctors such as likely cause(s), familial clustering, role of HLA tissue typing and diet (appropriately). Only a small percentage (4.2%) were counselled to actively seek screening for close family members. As HLA B27 presence is not diagnostic of ankylosing spondylitis, and it cannot be prevented or arrested even if diagnosed at onset or early stages, routine screening of close family members cannot be justified at present.
The monitoring and treatment of the diseases belonging to the concept of spondylarthropathy are related more to their clinical presentation, for example axial versus peripheral involvement, than to the precise diagnosis, for example, ankylosing spondylitis versus psorìatic arthritis. For each clinical presentation the treatment comprises local and systemic routes of administration but also drug and non-drug therapies.
To evaluate magnetic resonance imaging (MRI) guided corticosteroid injections of inflamed sacroiliac (SI) joints in patients with spondyloarthropathy with therapy resistant sacroiliitis. We performed 16 injections in 9 patients on an outpatient basis (6 men, 3 women, mean age at onset 24.7 +/- 7.5 yrs). All patients had MRI guided injection of 40 mg triamcinolone acetonide into SI joints using an open 0.2 Tesla unit. Before and 3 months after corticosteroid injection they underwent an MRI examination with a closed 1.5 Tesla unit. Seven of 9 patients reported subjective improvement that lasted at least a mean of 10.8 +/- 5.6 months. Subchondral bone marrow edema on fat suppressed images resolved in 8 patients after corticosteroid injection. MRI guided corticosteroid injection of SI joints appears to be an effective and safe procedure without exposure to radiation. It is a useful therapeutic modality, especially in young patients with severe isolated sacroiliitis.
The four clinical features of spondyloarthropathy, i.e. axial involvement, peripheral articular involvement, enthesopathy and extra-articular features, must be assessed in each patient suffering from spondyloarthropathy at each visit. The ASsessment in Ankylosing Spondylitis working group is establishing recommendations to facilitate the short- and long-term monitoring of patients suffering from spondyloarthropathies. Several relevant instruments are available for assessing the main domains, allowing evaluation of such patients - for example, pain, functional disability and spinal mobility. Other investigations are required in order to obtain relevant instruments for other domains, such as structural severity.
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