Chronic inflammatory back pain (IBP) is one of the characteristic features of axial spondyloarthritis (axSpA), but it’s not the only one that frontline healthcare professionals need to be mindful of when managing someone with this rheumatic disease.
Indeed, as axSpA may affect not only the sacroiliac and vertebral joints but also peripheral joints in the hands, wrists, elbows, shoulders, knees, ankles, and feet, people can experience a variety of joint and tendon aches and pains. There are also strong links to other inflammatory conditions that may be present even when IBP is not.
Extra-articular Manifestations (EAMs) of AxSpA
“It is important to remember that spondyloarthritis doesn’t only involve back pain,” physiotherapist Heather Harrison told Medscape Medical News. Harrison works alongside a rheumatology consultant in an IBP clinic in England and is a member of AStretch, an English not-for-profit organization that provides education and support to physiotherapists who help people with axSpA.
Enthesitis, plantar fasciitis, and Achilles tendinitis are just three of the nonspinal problems that people with axSpA may experience, but there are also “associated conditions” such as acute anterior uveitis, psoriasis, and inflammatory bowel disease (IBD).
These EAMs add to the morbidity of axSpA and “can cause patients to have reduced quality of life,” Harrison said.
“Asking patients about symptoms of these associated conditions can help with early diagnosis and optimum treatment,” so being aware of linked conditions is very important, she added.
How Likely Are You to See Extra-articular Features of AxSpA in Primary Care?
Published estimates on the prevalence of the main EAMs among people with axSpA and ankylosing spondylitis vary, but they tend to be in the same ballpark — at around 20%-30% for acute anterior uveitis, 5%-10% for psoriasis, and 5%-10% for IBD, which includes Crohn’s disease and ulcerative colitis.
The true prevalences of these conditions could be much higher, however, with studies suggesting that there is subclinical gut inflammation in 25%-49% of patients with axSpA, for example.
Like axSpA itself, the presence of the major histocompatibility complex 1 human leukocyte antigen (HLA)-B27 allele is strongly associated with having an EAM of the disease, although they can still occur in patients who are HLA-B27 negative.
While it’s important to look out for EAMs in people already diagnosed with axSpA, it is equally as important to be vigilant of undiagnosed axSpA in patients with one of the known EAMs.
In a recent review, whose authors include the axSpA experts Karl Gaffney, MBBCh, of Norfolk and Norwich University Hospitals NHS Foundation Trust, and Raj Sengupta, MBBS, of the Royal National Hospital for Rheumatic Diseases in Bath, England, it is pointed out that up to 78% of patients with anterior uveitis, 24% of those with psoriatic arthritis, and 40% of those with IBD may actually have axSpA.
How to Identify and Who Should Manage?
As to how patients with axSpA EAMs are identified and treated, it really depends on which is the main complaint for the patient and where they are referred to, Harrison said. If a patient has acute anterior uveitis, which is a very painful eye condition, then they are not going to be treated in primary care, as they need to go straight to the emergency department to see an ophthalmologist. Symptoms would include intense pain and redness in the eye, photophobia, and a reduction in visual acuity. There is also a tendency for this to recur, she noted.
Those with predominant bowel or skin issues may well be seen in primary care for a short while but will most likely be referred to see a gastroenterologist or dermatologist. Symptoms of IBD can include abdominal pain, diarrhea, weight loss, and blood loss, and there may be a family history. As for psoriasis, you’d be looking for red and scaly skin, which may be itchy and painful. There may again be a family history of the disease.
And of course, those with chronic suspected IBP and other characteristic features of axSpA (eg, age
Tricky Treatment Decisions
Treating axSpA EAMs can be tricky, as what works for one problem may not always work for another. While nonsteroidal anti-inflammatory drugs may be used to treat inflammation in axSpA before a patient receives a biologic, for example, these can be problematic for people with IBD as they may exacerbate the bowel disease. Disease-modifying antirheumatic drugs such as methotrexate and corticosteroids are often used to manage people with IBD, but these don’t tend to work for treating IBP.
“It’s a negotiation between specialties, if you like,” Harrison said.
A good example is the type of biological therapy. The aim would be to use a biologic that would be appropriate for both the gut and joint, or skin and joint symptoms, which usually means using an antitumor necrosis factor drug. But that’s a multidisciplinary decision, and it’s usually made in secondary care.
Good Communication and Cross-Referrals
Good communication and cross-referrals between specialties are thus critical to ensuring that the best treatment is received, Harrison said.
“We’ve obviously got patients that get referred to us from gastroenterology,” she said, “and then equally, we’ve got patients that we see in our clinic with bowel problems, and then we refer them over to gastroenterology.” Likewise for skin problems, she noted.
Harrison has been involved in educating nurses and other allied professionals in other specialties about the symptoms of axSpA, “so that they can hopefully identify patients within their clinics.”
As a minimum, “remember to check skin, eyes, bowels, and the entheses,” Harrison advised.
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Publish date : 2024-01-10 11:41:07
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