Ankylosing spondylitis

Ankylosing spondylitis - Chronic

 

Definition  

A chronic, progressive, inflammatory arthritis and enthesitis involving the axial skeleton, peripheral joints

 

Initial Evaluation: Testing  

 

Suspected and known ankylosing spondylitis  

* Pelvis X-ray: The first radiologic sign of ankylosing spondylitis is sacroiliitis, typically symmetric and bilateral, with changes more severe in the iliac area .

 

Suspected and known ankylosing spondylitis  

* Magnetic resonance imaging of pelvis: MRI is useful for detecting sacroiliitis if findings on pelvic x-rays are normal or equivocal and clinical suspicion of early disease is high .

 

Suspected and known ankylosing spondylitis  

* Erythrocyte sedimentation rate measurement: The erythrocyte sedimentation rate is useful for assessing posttreatment disease activity as an outcome measure of treatment efficacy .

 

Ankylosing spondylitis  

* Joint X-ray: Radiographic evidence of extra-axial synovial joints in ankylosing spondylitis includes joint space narrowing and erosions .

 

Ankylosing spondylitis  

* Radiography of spine: The earliest radiographic findings of spinal involvement in ankylosing spondylitis are small erosions (Romanus lesions) and adjacent sclerosis .

 

Ankylosing spondylitis  

* Magnetic resonance imaging of spine: MRI can be helpful for assessing disease activity by providing objective evidence of spinal inflammation and the response to treatment .

 

Medical History  

* Family history of Ankylosing spondylitis

* Past medical history of Human leukocyte antigen type

 

Findings  

* Low back pain

* Stiff back

* Arthralgia

* Decreased range of lumbar spine movement

* Musculoskeletal tenderness

* Chest expansion reduced

* Chest wall pain

 

Tests  

 

Suspected and known ankylosing spondylitis  

* Pelvis X-ray: The first radiologic sign of ankylosing spondylitis is sacroiliitis, typically symmetric and bilateral, with changes more severe in the iliac area .

 

Suspected and known ankylosing spondylitis  

* Magnetic resonance imaging of pelvis: MRI is useful for detecting sacroiliitis if findings on pelvic x-rays are normal or equivocal and clinical suspicion of early disease is high .

 

Suspected ankylosing spondylitis  

* CT of pelvis: CT should be considered if pelvic x-ray findings are normal or equivocal and clinical suspicion of early ankylosing spondylitis is high .

 

Ankylosing spondylitis  

* Joint X-ray: Radiographic evidence of extra-axial synovial joints in ankylosing spondylitis includes joint space narrowing and erosions .

 

Ankylosing spondylitis  

* Radiography of spine: The earliest radiographic findings of spinal involvement in ankylosing spondylitis are small erosions (Romanus lesions) and adjacent sclerosis .

 

Ankylosing spondylitis  

* Magnetic resonance imaging of spine: MRI can be helpful for assessing disease activity by providing objective evidence of spinal inflammation and the response to treatment .

 

Suspected and known ankylosing spondylitis  

* Erythrocyte sedimentation rate measurement: The erythrocyte sedimentation rate is useful for assessing posttreatment disease activity as an outcome measure of treatment efficacy .

 

Differential Diagnosis  

* Osteomyelitis of vertebra

* Septic arthritis - Acute

* Neoplasm of vertebral column

* Intervertebral disc prolapse

* Degenerative lumbar spinal stenosis

* Low back strain

* Rheumatoid arthritis - Chronic

* Post-infective arthritis

* Psoriasis with arthropathy

* Seronegative arthritis secondary to inflammatory bowel disease

 

Treatment  

 

Drug Therapy  

 

 

Ankylosing spondylitis with persistently high disease activity despite conventional treatments  

 

ETANERCEPT  

Adults: 25 mg subQ twice weekly 72 to 96 hours apart or 50 mg subQ once weekly (doses higher than 50 mg weekly are not recommended)

 

INFLIXIMAB

Adults: 5 mg/kg IV over 2 hours at 0, 2, and 6 weeks and every 8 weeks thereafter; frequency of administration may vary depending on clinical response

 

ADALIMUMAB  

Adults: 40 mg subQ every other week

 

 

Control of pain and stiffness in ankylosing spondylitis  

 

INDOMETHACIN

Adults: 25 to 50 mg orally 2 to 3 times daily (maximum 200 mg/day, 100 mg/dose) OR 75 mg (sustained release) orally 1 or 2 times daily

 

NAPROXEN

Adults: 250 to 500 mg orally twice daily (maximum 1,500 mg/day for up to 6 months) OR 275 or 550 mg orally twice daily (naproxen sodium) (maximum 1,650 mg/day for up to 6 months) OR 375 or 500 mg orally twice daily (naproxen EC) (maximum 1,500 mg/day for up to 6 months) OR two 375-mg or two 500-mg tablets orally once daily (naproxen sodium CR) (maximum three 500-mg tablets once daily)

 

DICLOFENAC SODIUM  

Adults: 25 mg (delayed-release) orally 4 times daily, with an extra 25-mg dose at bedtime if necessary (maximum 125 mg/day)

 

CELECOXIB  

 

 

 

Ankylosing spondylitis with recalcitrant enthesitis and persistent synovitis of peripheral joints  

 

TRIAMCINOLONE HEXACETONIDE - LIDOCAINE HYDROCHLORIDE  

Adults (knee, hip, or shoulder joint): Triamcinolone hexacetonide 10 to 20 mg intra-articular injection AND lidocaine 1 to 5 mL of a 1% solution injection; injections may be repeated every 3 to 4 weeks, if needed

Adults (interphalangeal joint): Triamcinolone hexacetonide 2 to 6 mg intra-articular injection AND lidocaine up to 1 mL of a 1% solution injection; injections may be repeated every 3 to 4 weeks, if needed

 

METHYLPREDNISOLONE ACETATE - LIDOCAINE HYDROCHLORIDE  

Adults (large joint): Methylprednisolone 20 to 80 mg intra-articular injection AND lidocaine up to 1 to 5 mL of a 1% solution injection

Adults (medium joint): Methylprednisolone 10 to 40 mg intra-articular injection AND lidocaine 1 to 3 mL of a 1% solution injection

Adults (small joint): Methylprednisolone 4 to 10 mg intra-articular injection AND lidocaine up to 1 mL of a 1% solution injection

 

 

Ankylosing spondylitis with peripheral arthritis  

 

SULFASALAZINE

Adults: 3 to 5 g/day orally

 

Procedural Therapy  

 

Ankylosing spondylitis  

* Physical therapy procedure: Physiotherapy is an essential part of the management of ankylosing spondylitis to reduce pain and stiffness and to improve function .

 

Non-Procedural Therapy  

 

Ankylosing spondylitis  

* Regular Exercise and Lifestyle Modifications