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.

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SpondyloarthropathiesAmor Criteria 1990

Amor B, et al. Rev Rheum Mal Osteoartic. 1990;57:85-89.

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Prevalence of AS & Related SpA (%)

Adapted with permission from Khan MA. Ann Intern Med. 2002;136:896-907.

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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.

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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