Comorbidities in spondyloarthritis 23.01.2014

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  • 1. Comorbidities SpA specific SpA unspecific Inflammatory bowel disease Psoriasis Uveitis Aortitis / aortic insufficiency Conduction disturbances (AV block) Apical pulmonary fibrosis Renal involvement Common cardiovascular diseases: coronary heart disease, arterial hypertension, stroke Osteoporosis Infections Malignancies

2. Extra-Articular Manifestations in Spondyloarthritis Concept related Eye-skin-gut-urogenital Frequent (20-60%) Clinical inflammation -At any moment of the disease evolution Sometimes related to axial or joint inflammation Effect of classical SpA drugs => Effect of TNF-blockers proven Not concept related Lung-kidney-heart-nerve Very rare (1%) Mostly subclinical -Long standing disease Not related to locomotor disease No effect of classical SpA drugs => Effect of TNF-blockers unknown 3. Inflammatory Bowel Disease 4. Anterior Uveitis Psoriasis IBD Combination Ever present 42% Not Present 58% 51% 10% 20% 19% n = 847 n = 355 Vander Cruyssen B et al. Ann Rheum Dis 2007;66:1072-7 Extra-Articular Manifestations in Ankylosing Spondylitis 5. Sensitivity Specificity LR+ LR- inflammatory back pain 71-75 % 75-80 % 3.1 0.33 enthesitis (heel pain) 16-37 % 89-94 % 3.4 0.71 peripheral arthritis 40-62 % 90-98 % 4.0 0.67 dactylitis 12-24 % 96-98 % 4.5 0.85 anterior uveitis 10-22 % 97-99 % 7.3 0.80 psoriasis 10-20 % 95-97 % 2.5 0.94 inflammatory bowel disease 5-8 % 97-99 % 4.0 0.97 positive family history for SpA 7-36 % 93-99 % 6.4 0.72 good response to NSAIDs 61-77 % 80-85 % 5.1 0.27 elevated acute phase reactants 38-69 % 67-80 % 2.5 0.63 HLA-B27 (axial involvement) 83-96 % 90-96 % 9.0 0.11 Sacroiliitis on MRI 60-85 % 90-97 % 20.0* 0.41 Sacroiliitis ( grade 3) on x-rays 40% 98 % 20.0* 0.61 Ankylosing Spondylitis / Axial Spondyloarthritis Typical Manifestations Positive likelihood ratio (LR+) = sensitivity / (100 specificity) Negative likelihood ratio (LR-) = (100 sensitivity) / specificity Modified from: Rudwaleit M et al. Ann Rheum Dis 2006;65:1251-2 * best estimate It is recommended to ignore a negative test result of these tests in an early state of possible axial SpA 6. Frequency of SpA manifestations in the GESPIC cohort Rudwaleit M, et al. Arthritis Rheum 2009;60:717-27. AS (n=236) non-radiographic axial SpA (n=226) Inflammatory back pain, ever 98.7% 100% Peripheral arthritis 37.4% 40.9% Enthesitis 39.4% 43.6% Uveitis 20.9% 12.4% Dactylitis 6.3% 4.0% Psoriasis 10.2% 9.8% Inflammatory bowel disease 2.6% 1.8% 7. Typical Gut Lesions in Crohns Disease Crohns disease lesions in the colon with deep ulcerations and islands of regenerative mucosa in between. 8. Bakterium T- Zelle IBD SpA T-Cells Bacteria Identical (CD8+) T-cell expansions in the colon mucosa and the synovium of a patient with enterogenic spondyloarthropathy. Hypothesized relationship between IBD and SpA May E, et al. Gastroenterology 2000;119:1745-55. 9. inflammatory gut lesions in SpA without associated gastrointestinal symptoms Inflammatory gut lesions: Macroscopic: ~30% Microscopic: ~60% (1/3 acute und 2/3 chronic, Crohn-like lesions) Mielants H, et al. Br J Rheumatol 1988;27 Suppl 2:95-105. De Vos M, et al. Gastroenterology 1989;96:339-44. Mielants H, et al. J Rheumatol 1995;22:2273-8. 10. normal acute chronic reactive arthritis undifferentiated SpA Ankylosing spondylitis Inflammatory gut lesions in various forms of SpA without associated gastrointestinal symptoms Mielants H, et al. J Rheumatol 1995;22:2273-8. 11. Van Praet L, et al. Ann Rheum Dis 2013;72:414-7. Inflammatory gut lesions in SpA 12. Active SpA 3 13 4 1 11 16 patients 6 9 1 14 SpA in remission 15 patients Acute Chronic Normal Evolution of SpA and inflammatory gut lesions over time Mielants H, et al. J Rheumatol 1995;22:2273-8. Follow-up: 2 bis 9 years Remission of joint inflammation in SpA was always associated with disappearance of gut inflammation, whereas persistence of locomotor (joint) inflammation was mostly associated with persistence of gut inflammation. 13. Colombel JF, et al. N Engl J Med 2010;362:1383-95. SONIC-Studie: Infliximab, Azathioprine, or Combination Therapy for Crohns Disease 14. Efficacy of Anti-TNF-Therapy in Crohns Disease Response (CDAI score