Transcript Khan_AS_US_Meeting24..

Organizational Meeting for
the AS-US Working Group
Advancing Clinical Research
in AS and SpA in the USA
Spondylitis Association of America
20 Years of Setting the Course
Concluding Remarks
Muhammad Asim Khan, MD, MACP, FRCP
Professor of Medicine
Case Western Reserve University
Cleveland, Ohio, USA
The Spondyloarthropathies
Ankylosing
Spondylitis
Psoriatic
Arthritis
Juvenile SpA
Undiff SpA
Arthritis
associated with
Ulcerative colitis
Crohn’s dis
Reactive arthritis
Estimates of Prevalence of
SpA in the US 1998 Report*
• 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
*Lawrence RC, et al. Arthritis Rheum 1998; 41:778-799
Prevalence of PsA
No population-based US study
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
1Gran
2 Riise
JT, Husby G, Hordvik M. Ann Rheum Dis 1985; 44: 359-67.
et al. J Rheumatol 2000; 27: 1386-9.
7
Spondyloarthropathies
ESSG Criteria
Dougados M, et al. Arthritis Rheum. 1991 Oct;34(10):1218-1227.
8
Spondyloarthropathies
Amor Criteria 1990
Amor B, et al. Rev Rheum Mal Osteoartic. 1990;57:85-89.
Prevalence of AS & Related SpA (%)
10
Adapted with permission from Khan MA. Ann Intern Med. 2002;136:896-907.
Sacroillitis: Most Common Among The
Spondyloarthropathies
Ankylosing
Spondylitis
Psoriatic
Arthritis
Juvenile SpA
Entheitis
Sacroiliitis
Synovitis
Arthritis
associated with
Ulcerative colitis
Crohn’s dis
Undiff SpA
Reactive arthritis
Reiter syndrome
ENTHESITIS
ENTHESIS
• Compact fiber bundles
region
• Fibrocartilage, nonmineralized
• Mineralized fibrocartilage
• Lamellar bone
Braun, Khan, Sieper. ARD 2000; 59: 985-94
a) MRI of the SI joints
c) MRI subtraction evaluation
Enhancement of SI joints
(synovial part & juxta-articular
bone (‘bone edema’)
Khan MA: In: Hochberg et al.
RHEUMATOLOGY, (3rd Ed.) 2003, (in press).
b) 5 minutes after gadolinium inj.
(Courtesy of M. Rudwaleit and J. Sieper.)
Khan MA: In: Hochberg et al. RHEUMATOLOGY, (3rd Ed.) 2003, (in press).
How to make an early diagnosis?
Probability of AS/Axial SpA in Patients With Back Pain
Chronic Back Pain
Inflammatory Back Pain
5%
Underwood & Dawson
Brit J Rheumatol 1995.
14%
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)
30-70%
95%
probability
AS/Axial SpA
Courtesy Rudwaleit & Sieper
Khan MA. Ankylosing spondylitis: Clinical features. In: Hochberg et al (Eds).
RHEUMATOLOGY, (3rd Edition). London, Mosby. 2003.
HLA B27 Distribution
25
30
40
16 24
19-34
40
8
50
HLA B2709
HLA B2706
0
0
0
Khan MA. Current Opin Rheumatol 1995;7:263-269.
Noncompliance:
The Other “Drug Problem”
Rates of non-compliance with arthritis
therapy ranges from 22% to 75%
Maetzel et al.
Rheumatology 2000; 39:975.
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 Univ 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 University 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
Khan MA.
Ankylosing Spondylitis: The facts. 2002, Oxford Univ Press.
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