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Organizational Meeting for the AS-US Working Group
Advancing Clinical Researchin AS and SpA in the USA
Spondylitis Association of America
20 Years of Setting the Course
Muhammad Asim Khan, MD, MACP, FRCP
Professor of Medicine
Case Western Reserve University
Cleveland, Ohio, USA
Concluding Remarks
Juvenile SpAJuvenile SpA
Reactive arthritisReactive arthritis
The Spondyloarthropathies
Arthritis Arthritis associated withassociated with
Ulcerative colitis Ulcerative colitis Crohn’s disCrohn’s dis
Psoriatic Psoriatic ArthritisArthritis
Ankylosing Ankylosing
SpondylitisSpondylitis
Undiff SpAUndiff SpA
Estimates of Prevalence of SpA in the US 1998 Report*
*Lawrence RC, et al. Arthritis Rheum 1998; 41:778-799
• 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
Prevalence of PsA
No population-based US study
1Gran JT, Husby G, Hordvik M. Ann Rheum Dis 1985; 44: 359-67.2 Riise et al. J Rheumatol 2000; 27: 1386-9.
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
SpondyloarthropathiesESSG Criteria
Dougados M, et al. Arthritis Rheum. 1991 Oct;34(10):1218-1227.
7
SpondyloarthropathiesAmor Criteria 1990
Amor B, et al. Rev Rheum Mal Osteoartic. 1990;57:85-89.
8
Prevalence of AS & Related SpA (%)
Adapted with permission from Khan MA. Ann Intern Med. 2002;136:896-907.
10
Juvenile SpAJuvenile SpA
Reactive arthritisReactive arthritisReiter syndromeReiter syndrome
Sacroillitis: Most Common Among The Spondyloarthropathies
Arthritis Arthritis associated withassociated with
Ulcerative colitis Ulcerative colitis Crohn’s disCrohn’s dis
Psoriatic Psoriatic ArthritisArthritis
Ankylosing Ankylosing
SpondylitisSpondylitis
Undiff SpAUndiff SpA
EntheitisEntheitis
SacroiliitisSacroiliitis
SynovitisSynovitis
ENTHESITIS
• Compact fiber bundles region
• Fibrocartilage, non-mineralized
• Mineralized fibrocartilage
• Lamellar bone
ENTHESIS
Braun, Khan, Sieper. ARD 2000; 59: 985-94
c) MRI subtraction evaluation
Enhancement of SI joints (synovial part & juxta-articular bone (‘bone edema’)
(Courtesy of M. Rudwaleit and J. Sieper.)
Khan MA: In: Hochberg et al. RHEUMATOLOGY, (3rd Ed.) 2003, (in press).
a) MRI of the SI joints
b) 5 minutes after gadolinium inj.
Khan MA: In: Hochberg et al. RHEUMATOLOGY, (3rd Ed.) 2003, (in press).
AS/Axial SpA
95% probability
5%
14%
30-70%
Inflammatory Back Pain
Any one of the additional clinical features:
e.g. enthesitis, positive family history, uveitis, asymmetric arthritis, positive response to NSAIDs, etc.
Imaging = X-rays
If negative, then CT or MRI
(or HLA-B27)
Khan MA. Ankylosing spondylitis: Clinical features. In: Hochberg et al (Eds). RHEUMATOLOGY, (3rd Edition). London, Mosby. 2003.
How to make an early diagnosis?
Chronic Back Pain
Probability of AS/Axial SpA in Patients With Back Pain
Courtesy Rudwaleit & Sieper
Underwood & DawsonBrit J Rheumatol 1995.
HLA B27 Distribution
HLA B2709HLA B2709
HLA B2706HLA B2706
5050
4040
2525 3030 242419-3419-34 4040
00
00
00
Khan MA. Current Opin Rheumatol 1995;7:263-269.
16
8
Maetzel et al. Rheumatology 2000; 39:975.
Noncompliance: The Other “Drug Problem”
Rates of non-compliance with arthritis
therapy ranges from 22% to 75%
Khan MA. Ankylosing Spondylitis: The facts. 2002, Oxford Univ Press.
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 University Press
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 Univ. Press.
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
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
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