Back pain in young people possibly due to AS
Further investigation of back pain in the below 30 age group may lead to early diagnosis of ankylosing spondylitis (AS), says an expert.
“Ankylosing spondylitis is a chronic condition that causes back pain because of inflammation of ligaments between the vertebra and inflammation of the tendons and ligaments,” said Dr. Amir Azlan Zain, consultant physician and rheumatologist, at a media briefing on AS in Kuala Lumpur.
The inflammatory back pain experienced by patients with AS is the opposite of mechanical back pain. It improves when they move and worsens with rest. The early morning stiffness usually lasts for hours. These two symptoms are cardinal in inflammatory back pain. “Awareness of AS has to be not only amongst the members of the public but also members within the medical community as well including family physicians, orthopaedic surgeons and professionals who also evaluate people with back pain on a regular basis,” said Amir.
AS is in a group of conditions, which is typified by long-term inflammation. If the inflammation is left unchecked, it can lead to progressive stiffening of the areas involved. In the case of the intervertebral ligaments, it causes a stiffening of the spine. This process is irreversible. [Spondylitis Association of America. Available at: www.spondylitis.org Accessed on 30 May]
Other comorbidities associated with AS include cardiovascular complications, osteoporosis, reduced pulmonary function, chronic pain, depression and gastrointestinal problems. Patients with AS are also at a higher chance of dying compared with the general population. [Arthritis Rheum 2011;63:1182–1189, Ann Rheum Dis 2011;70:1921–1925]
AS is an autoimmune disease whereby the immune system has been switched on via trigger and the immune cells—mostly white blood cells (WBC)—are activated and produce inflammatory substances. These inflammatory substances drive the inflammation in the spine and cause the eventual stiffening of the spine. The HLA-B27 is a genetic marker found in most of the human cells and 90% of people with AS have it although it is a fairly common genetic marker in general.
The prevalence of AS is much higher in North America (3,190 per million) and Europe (2,380 per million) but there is a fair number in Asia (1,670 per million). [Rheumatology (Oxford) 2014;53:650–657] AS affects young people and is diagnosed when patients are at the most productive age in terms of work productivity. [Curr Opin Rheumatol 2000;12:239–247] As a result, 30% of patients with AS have to quit their job because they are unable to sustain the job in the long term. [Curr Rheumatol Rep 2010;12(5):325–331]
Diagnosing AS is fairly straightforward and involves firstly, the recognition that back pain is inflammatory and secondly, through specific physical examination especially of the spine. Tests for inflammation and HLA-B27 are recognized as standard tests for inflammatory back pain. X-ray or magnetic resonance imaging (MRI) changes are now important in classification of AS, said Amir.
In terms of treatment, only anti-inflammatory tablets and physiotherapy were available until about 18 years ago. The emergence of tumour necrosis factor (TNF) inhibitors—so-called biologic medicines—have changed the treatment landscape for patients with AS. There are five anti-TNF medicines that are licensed for use in Malaysia, he said.
The newly available secukinumab (Cosentyx®) targets a completely different pathway ie, IL-17A. Inflammatory substances produced by WBC include TNF and IL-17A. Blocking these molecules has been effective in controlling AS, said Amir.
Speaking on Arthritis Foundation, Malaysia (AFM), its president Associate Professor Dr. Sargunan Sockalingam, consultant rheumatologist, University Malaya Specialist Centre, said, “AFM was founded in 1994 and an organization for people involved in the care of arthritis patients and also of people living with arthritis.”
AFM is a support group for people with rheumatoid arthritis, psoriatic arthritis, osteoarthritis and, more recently, AS. AFM organizes fundraising activities in terms of public forums, support group platforms with meetings and activities and weekly exercise sessions. The Arthritis Fund, which was established sometime in 1995, provides partial or full financial support for joint replacements and plans to include biologics. AFM held a fundraising run in May for the Arthritis Fund. For further information on AFM, go to www.afm.org.my