6/6/2017. Spondyloarthritis and Osteopathic Primary Care: Facts and Challenges. Progression of Ankylosing Spondylitis Classic Disease

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Gertrude Lyons
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Outline Talk 1 Introduction of spondyloarthritis (SpA) Clinical case challenge The problem of low back pain (LBP) in primary care and in osteopathic primary care Talk 2 What is SpA

2 Outline Talk 1 Introduction of spondyloarthritis (SpA) Clinical case challenge The problem of low back pain (LBP) in primary care and in osteopathic primary care Talk 2 What is SpA today? How many people in the United States have SpA? How do we diagnose SpA? Treating SpA does it make a difference? Patients today with SpA different from what I learned in medical school 2

Spondyloarthritis and Osteopathic Primary Care: Facts and Challenges FACT: Spondyloarthritis and its associated subtypes are common causes of chronic low back pain (CLBP) in young people.

3 Spondyloarthritis and Osteopathic Primary Care: Facts and Challenges FACT: Spondyloarthritis and its associated subtypes are common causes of chronic low back pain (CLBP) in young people. FACT: There is often a long delay (8 to 10 years) from symptom onset to diagnosis. FACT: There have been great advances in both the diagnosis and treatment in recent years, which can greatly improve outcomes in SpA. FACT: The majority of individuals with SpA spectrum diseases are not diagnosed in clinical practice. FACT: As many as 1 in 4 patients with CLBP aged <40 years in primary care settings may have SpA. CHALLENGE: Doctors of Osteopathic Medicine (DOs) care for a disproportionate number of patients with CLBP of younger ages and are caring for unrecognized patients with SpA. Tools are needed to recognize, optimally treat, and refer such patients for advanced care when needed. Progression of Ankylosing Spondylitis Classic Disease Little H, et al. Am J Med. 1976;60(2): : Ankylosing Spondylitis is Now Recognized as Part of the Spondyloarthritis Spectrum 3

4 Case A 38-year-old woman has been under care for 11 months for CLBP of several years duration. Her past medical history is notable for mild fibromyalgia and highly localized breast cancer with negative nodes that was treated with surgery and adjuvant chemotherapy 8 years ago. Her fibromyalgia has been doing well with some aerobic exercise and trazodone at bedtime for sleep. Her back pain began insidiously and is poorly localized to the lumbosacral area. It occasionally radiates to one or the other buttock. It is often dull, but it can be sharp and severe, with stiffness, particularly on awakening. She has used over-the-counter ibuprofen with moderate relief, but she does not like to take medicine. She also notes that her back pain improves with walking or jogging. Case (continued) On examination, she is noted to have tight hamstrings but has no true radicular pain on straight leg raising. She is unable to touch her toes, with 3- inch finger to floor. Her neurologic examination is normal, as is strength. She has no other red flags (ie, weight loss, constitutional symptoms, fever, weight loss). Her family history is negative for spinal disease, psoriasis, inflammatory bowel disease, and eye disease. Plain radiographs of her lumbosacral spine are normal, as is pelvic X-ray. General laboratory tests are normal, including CBC and CMP, her WSR is 19 mm/hr and her CRP is 0.9 mg/l. Case (continued) She seeks the care of an osteopathic physician, as she has an aversion to medications and believes they are merely a band aid for her problem, so she wishes an alternative approach. After evaluation, no further findings were uncovered, and she was treated with osteopathic manipulative medicine every 2 weeks for 6 weeks, mostly consisting of myofascial release, strain counterstrain, and highvelocity/low-amplitude thrusts. Following each treatment, she improves considerably, but in a few days her pain returns and she is in more pain than ever. It is now 8 months later and she tells you that in the morning she can hardly clean herself after using the toilet due to back stiffness and pain. 4

Case (continued) The patient undergoes an MRI of the sacroiliac (SI) joints and demonstrates significant bone edema and evidence of SI synovitis. An HLA-B27 was performed, which was negative.

5 Case (continued) The patient undergoes an MRI of the sacroiliac (SI) joints and demonstrates significant bone edema and evidence of SI synovitis. An HLA-B27 was performed, which was negative. She was referred to a rheumatologist for further diagnostic and therapeutic considerations. She was diagnosed with ankylosing spondylitis (AS) and prescribed full-dose nonsteroidal anti-inflammatory drugs (NSAIDS) and physical therapy, but after 4 months she still had significant pain and loss of function. A tumor necrosis factor (TNF) inhibitor was added to her regimen, and her symptoms dramatically regressed; she resumed full activities and exercise. Spinal Pain COMMON and COSTLY Most Common Pain Syndromes United States 2002 National Health Interview Survey 1. Low back pain 26.4% 2. Severe headache 15.0% 3. Neck Pain 13.8% 4. Face/jaw 4.6% United States Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, ICPSR04176-v4. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor],

6 Back and Neck Pain Lifetime incidence in adults: Neck pain: 71% Back pain: 85% Low back pain accounts for 2.5% of all physician office visits Annual incidence of compensable back injury in workers: 2% Trinh K, et al. Spine (Phila Pa 1976). 2007;32(2): Schmidt CO, et al. Spine (Phila Pa 1976). 2007;32(18): National Ambulatory Medical Care Survey Accessed May 18, Andersson GB. Lancet. 1999;354(9178):581-5 Red Flags Underlying systemic diagnosis clues that may suggest an underlying systemic diagnosis include: History of cancer Age 50 years and older Unexplained weight loss Duration of pain greater than 1 month Nighttime pain Unresponsiveness to previous therapies Inflammatory back pain Challenges of Detecting Spondyloarthritis in Primary Care There often is a gap of 8 to10 years before securing a diagnosis of SpA. The diagnosis may not be straightforward, with many nuanced presentations. Spondyloarthritis is not uncommon, but the majority of patients have not been diagnosed. Multiple studies in primary care settings throughout the world demonstrate as many as 1 in 5 patients may have hidden SpA. Some studies demonstrate that as many as 25% of young patients in primary care practices with CLBP may have SpA. van Hoeven L, et al. Arthritis Care Res. 2014;66(3):

7 Osteopathic Medicine 129,649 practitioners and medical students in 2016 DOs are more likely to provide care in primary care and general medicine settings than MDs Osteopathic Medical Profession Report Accessed May 18, Licciardone JC, et al. BMC Health Serv Res. 2011;11:303. Osteopathic Medicine and Low Back Pain The National Ambulatory Medical Care Survey 2004 study attributes 61 million patient visits to LBP, with 41 million exclusively for LBP DOs versus MDs were more likely to provide care for LBP (odds ratio [OR] 2.61; 95% confidence interval [CI], ) and chronic LBP (OR 4.39; 95% CI, ) DOs versus MDs less likely to prescribe NSAIDS (OR, 0.40; 95% CI, ) and to refer patients to another physician DOs are enriched for patients under their care with CLBP aged <45 years Licciardone JC, et al. Osteopath Med Prim Care. 2008;2:5. Licciardone JC. J Am Osteopath Assoc. 2015;115(12): DOs Care for an Inordinate Population of AS/SpA Patients DOs likely care for an inordinate population of patients with AS/SpA, with the majority being unrecognized. Our challenge is to answer the questions: How can we better understand LBP secondary to SpA and recognize it in our practices? How should we proceed to screen and diagnose patients for back pain secondary to SpA in our practices? What are the basic principles and optimal therapy for all patients with back pain secondary to SpA? What are the major advances in therapy we should be aware of? When is it appropriate to refer patients with SpA to rheumatologists or other specialists with expertise in SpA diseases? 7

8 What Are We Going to Discuss Today? What is SpA today? How many people in the United States have SpA? How do we diagnose SpA? Imaging Inflammatory back pain Genetics Treating SpA does it make a difference? Patients today with SpA different from what I learned in medical school Concept of Spondyloarthritis 8

1 cases per 1000 adult population (Age > 15 years): { 0.

9 Epidemiology: How Many People in the United States Have SpA? National Arthritis Data Workgroup Estimates of Prevalence of SpA in the United States Report 2.1 cases per 1000 adult population (Age > 15 years): { 0.21% } (1990 population), based on studies using classification criteria, including X-ray evidence of sacroiliitis Was this a real epidemiology? Lawrence RC, et al. Arthritis Rheum. 1998;41(5): Khan MA. Curr Opin Rheumatol. 1995;7(4):

10 Correlation of Ankylosing Spondylitis and HLA-B27 Prevalence Group Prevalence of AS (%) Frequency of HLA-B27 (%) Haida Amerinds Norway Germany United States Netherlands China Gofton JP, et al. Ann Rheum Dis.1966;25(6): Gran JT, et al. Ann Rheum Dis.1985;44(6): Braun J, et al. Reply. Arthritis Rheum. 2005;52: Maurer K. Vital Health Stat. 1979;11: van der Linden SM. Arthritis Rheum. 1984;27(3): Zeng QY, et al. Arthritis Res Ther. 2008;10(1):R17. How Do We Find Out Who Has AS Today? Inflammatory back pain: its origins and utility for both epidemiology and diagnosis Clinical History as a Screening Test for Ankylosing Spondylitis Andrei Calin, MA, MRCP; Jean Porta, MS; James F. Fries, MD; David J. Schurman, MD Calin A, et al. JAMA. 1977;237(24):

known HLA-B27-positive participants with AS by NY Criteria 21 patients from an orthopedic clinic who were HLA-B27 negative and had normal X-rays of the SI joints 75 controls who were healthy or

11 Pay attention to questions 4, 8, 12, 14, 15, and 16 do they sound familiar? Thus Began the Study of Inflammatory Back Pain as a Case Ascertainment Tool in the Clinic Questionnaires containing 17 questions relating to back pain were given to 3 groups of participants 42 known HLA-B27-positive participants with AS by NY Criteria 21 patients from an orthopedic clinic who were HLA-B27 negative and had normal X-rays of the SI joints 75 controls who were healthy or were attending non-rheumatology clinics The following 5 characteristics distinguished AS from other types: age less than 40 years, insidious onset, duration of at least 3 months, morning stiffness, and improvement with exercise NHANES Mobile Exam Center (MEC) NHANES = National Health and Nutrition Examination Survey. 11

12 How Often is IBP Seen in the United States Population? The NHANES Results Overall chronic back pain in the US population was almost 20% Age-adjusted US prevalence of IBP by Calin et al criteria was 5.0% (95% CI, ), 5.6% by ESSG criteria, and 5.8% or 6.0% by various Berlin criteria. There was no difference among age groups or between men and women. There were differences among ethnicities: IBP prevalence was significantly lower among non-hispanic black persons compared with non-hispanic white persons. Non-Hispanic white persons had higher IBP compared with Mexican-American persons. ESSG = European Spondyloarthropathy Study Group. Calin A, et al. JAMA. 1977;237(24): What are the US SpA Estimates Using the 2 Published Sets of Classification Criteria Amor and ESSG? The NHANES data collection fully supported both ESSG inflammatory spinal pain and Amor back pain/stiffness case definitions. The overall age-adjusted prevalence of definite and probable SpA by the Amor criteria was 0.9% (95% CI, ) and by ESSG criteria was 1.4%. There were no sex differences. These estimates were in the range of 0.35% to 1.30% published in 2008 by the US National Arthritis Data Workgroup, which basically summed published prevalence estimates for the various SpA subgroups. How Else Do You Make a Diagnosis of AS Today? Advanced Imaging 12

SpA Evolution Non-radiographic stage Radiographic stage Modified New York Criteria 1984 Back pain Sacroiliitis on MRI Back pain Radiographic sacroiliitis Back pain Syndesmophytes Time (years)

13 SpA Evolution Non-radiographic stage Radiographic stage Modified New York Criteria 1984 Back pain Sacroiliitis on MRI Back pain Radiographic sacroiliitis Back pain Syndesmophytes Time (years) Rudwaleit M, et al. Arthritis Rheum. 2005;52: The Role of MRI MRI is the imaging option of choice for patients with suspected axspa and normal plain x-rays T2 fat-suppressed sequences (STIR) bone marrow edema (BME) T1 reveals structural damage such as erosions, sclerosis, fat deposition, and ankylosis Gadolinium is not indicated Step 3: Laboratory Testing Symptoms Imaging Lab IBP Sacroiliitis X-ray ESR / CRP Enthesitis Sacroiliitis - MRI Uveitis CRP = C-reactive protein. 13

14 Oblique Transverse Section Normal Left SI Joint Madsen KB, et al. J Rheumatol. 2010;37(2): T1 STIR 14

had AS by another rheumatologist Ready to go away to college HLA-B27 negative

15 Who are the Current Patients with SpA we are Seeing in the United States? Case Presentation 17-year-old boy with back pain Anxious mother He was told he had AS by another rheumatologist Ready to go away to college HLA-B27 negative Wants a second opinion because of a positive MRI (which turned out to be negative) 15

revealing fusion of her lumbar spine She has little back pain (not inflammatory) No

16 Case of an HLA-B27 Positive Patient and a Radiographic Abnormality The patient is a 53-year-old female attorney referred for a positive radiograph for AS. revealing fusion of her lumbar spine She has little back pain (not inflammatory) No history of skin, eyes, joints, or gut inflammation HLA-B27 test is positive Patient is worried 16

Peripheral SpA in 2016 58-year-old healthy woman, active tennis player One-year history of right foot

17 Enthesitis Entheses: areas of insertion of tendons, ligaments, fascia, and joint capsules on bone Aquino MR, et al. Pediatr Radiol. 2015;45(5): Peripheral SpA in year-old healthy woman, active tennis player One-year history of right foot pain and swelling Occasional buttock pain, left side No other SpA features for herself or family Normal pelvis X-ray; no response to steroids or NSA HLA-B27 positive 17

For pain location, he points directly over the lateral upper thighs Examination reveals

18 Case Presentation Hip Pain The patient is a 19-year-old man with bilateral hip pain for 2 years Back pain is fairly longstanding not paid very much attention by the patient in recent years For pain location, he points directly over the lateral upper thighs Examination reveals exquisite tenderness over the greater trochanters bilaterally HLA-B27 test is positive BB, 19 y/o male 18

onset Back pain not necessarily present at onset Adverse

19 Features that are Atypical but Typical Today Female Older age of onset HLA-B27 negative Peripheral arthritis at onset Back pain not necessarily present at onset Adverse reaction to anti-tnf drugs Less responsive to anti-tnf drugs 19

20 Who has SpA Today Using Clinical Criteria? 1% of the general population 3% of HLA-B27 positive 5% of CLBP 15% of IBP >25% of age <45 years with IBP with other features Treatment of AS Do NSAIDs work? What about TNF agents efficacy, safety, and potential disease-modifying potential Do Anti-TNF Agents Truly Change the Bone Progression of AS? 20

AS: Efficacy of TNF-α Inhibitors Davis JC Jr., et al. Arthritis Rheum. 2003;48(11):3230-6. van der Heijde D, et al.

(ASSERT) Inman RD, et al. Arthritis Rheum. 2008;58(11):3402-1. (GO-RAISE) Landewé R, et al. Ann Rheum Dis. 2014;73(1):39-47.

21 AS: Efficacy of TNF-α Inhibitors Davis JC Jr., et al. Arthritis Rheum. 2003;48(11): van der Heijde D, et al. Arthritis Rheum. 2006;54(7): (ATLAS) van der Heijde D, et al. Arthritis Rheum. 2005;52(2): (ASSERT) Inman RD, et al. Arthritis Rheum. 2008;58(11): (GO-RAISE) Landewé R, et al. Ann Rheum Dis. 2014;73(1): (RAPID-axSpA) Anti-TNFα Therapy Over 2 Years does not Inhibit Radiographic Progression in AS Haroon N, et al. Arthritis Rheum. 2013;65(10):

22 msasss = modified Stokes Ankylosing Spondylitis Spine Score. Haroon N, et al. Arthritis Rheum. 2013;65(10): Haroon N, et al. Arthritis Rheum. 2013;65(10): Environment Microbes Mechanics Genetics HLA-B27 Other genes Interesting Biology Spondyloarthritis Courtesy of Judy Smith 22

23 What Happens if you do not Treat the Patient? Problem of a Positive X-ray not Read Correctly 31-year-old engineer 10-year history of IBP with bilateral buttock pain 2010 bilateral decompression laminectomies at L4-S1; micro-diskectomy at L persistent back pain resulted in L4-5 transforaminal lumbar interbody fusion 2014 persistent hip pain resulted in pelvis MRI revealing inflammation 2015 happy patient; TNF blocker June 2,

24 January 18, 2012 March 12, 2012 March 12,

25 July 28, 2014 August 14, year-old man HLA-B27 positive Radiographic progression from 2007 to

26 May 2007 January 2010 November

27 August Coronal T1 versus STIR 27

28 28

29 29

30 Taking a Critical Look at SpA in 2016 Today, as many women as men are being diagnosed with SpA 1% of the population, 5% of CLBP, 15% of IBP have SpA MRI is important; beware of false-positives and falsenegatives Role of HLA-B27, physical force, microbial triggers Anti-TNF drugs they DO prevent damage Current thinking: interleukin-23 as a key cytokine is it true? Take-home Points Screening for IBP is key (case-ascertainment, not screening) Patients with SpA are enriched if age is less than 45 years HLA-B27 is a good test in a screened patient, but beware of falsepositives (6% of the population) and HLA-B27 negative cases Patients DO get better with biologic drugs, so refer Do you order an MRI? Yes, if you know your radiologist and in the right patient 30

31 * Please return your completed YELLOW EVALUATION and PRACTICE CHANGE REMINDER POSTCARD by placing it in the center of the table for collection immediately upon conclusion of this session. 31

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