ankylosing%20spondylitis
ANKYLOSING SPONDYLITIS
Spondyloarthritis refers to a group of inflammatory diseases characterized by spinal & joint oligoarthritis, enthesitis, and sometimes mucocutaneous, ocular and/or cardiac manifestations.
Ankylosing spondylitis is a prototype of spondyloarthritis, particularly of the axial form.
Diagnosis of ankylosing spondylitis is definite if any of the radiological criterion (grade≥2 bilateral sacroiliitis or grade ≥3 unilateral sacroiliitis) is associated with at least one of the clinical criterion (low back pain & stiffness for >3 months that improves with exercise but not relieved by rest, limitation of motion of the lumbar spine in the sagittal and frontal planes, limitation of chest expansion relative to normal values correlated for age and gender.

Diagnosis

Diagnosis of Spondyloarthritis (SPA)

Assessment in SpondyloArthritis international Society (ASAS) Criteria

  • Recommended for patients with axial spondyloarthritis (SPA) with ≥3 months back pain and <45 years of age at the time of onset
  • Preferred diagnostic criteria for patients without radiographic sacroiliitis
  • Has the highest sensitivity score compared to other criteria for spondyloarthropathies
  • Imaging Arm - requires 1 clinical parameter and sacroiliitis
    • Sacroiliitis shows positive grade 2 bilateral or grade 3-4 unilateral radiographic disease
    • Positive acute inflammation of sacroiliac joints on magnetic resonance imaging (MRI), highly suggestive of sacroiliitis
  • Clinical Arm - requires a positive human leukocyte antigen-B27 (HLA-B27) test and 2 clinical parameters
  • Clinical parameters:
    • Inflammatory back pain
    • Arthritis
    • Psoriasis
    • Good response to non-steroidal anti-inflammatory drugs (NSAIDs)
    • Human leukocyte antigen-B27 (HLA-B27) positive
    • Dactylitis
    • Crohn’s disease/colitis
    • Positive family history of spondyloarthritis (SPA)
    • Enthesitis
    • Increased C-reactive protein (CRP)
    • Uveitis
European Spondyloarthropathy Study Group (ESSG) Criteria
  • Inflammatory spinal pain or synovitis
    • Synovitis may be asymmetric or predominantly in the lower extremities
    • Required criteria to make the diagnosis of ankylosing spondylitis (AS)
  • And 1 or more of the following:
    • Positive family history
    • Psoriasis
    • Inflammatory bowel disease
    • Enthesopathy
    • Sacroiliitis
    • Urethritis, cervicitis, or acute diarrhea within 1 month prior to occurrence of arthritis
    • Alternating pelvic pain between the left and right gluteal areas
Amor Criteria
  • According to the Amor criteria, patients with a total score of ≥6 based on symptoms and clinical history indicates spondyloarthritis (SPA)
  • 1 point each
    • Lumbar or dorsal pain at night or morning stiffness of lumbar or dorsal spine
    • Buttock pain
    • Non-gonococcal urethritis or cervicitis accompanying or within 1 month before onset of arthritis
    • Acute diarrhea accompanying or within 1 month before onset of arthritis
  • 2 points each
    • Asymmetric oligoarthritis
    • Buttock pain alternately affecting the right or left buttock
    • Sausage-like toe or digit (dactylitis)
    • Heel pain or any other well-defined enthesitis
    • Iritis
    • History of psoriasis, balanitis, or inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
    • Presence of human leukocyte antigen (HLA)-B27
    • Familial history of ankylosing spondylitis (AS), Reiter syndrome, uveitis, psoriasis, or chronic encephalopathies
    • Good response to non-steroidal anti-inflammatory drugs (NSAIDs) in 48 hours or relapse of pain in <48 hours upon discontinuation
  • 3 points for sacroiliitis (grade ≥2 if bilateral, grade ≥3 if unilateral)

Diagnosis of Ankylosing Spondylitis (AS)

Based on the Modified New York criteria (1984), definite ankylosing spondylitis (AS) is defined when any of the radiological criterion is associated with at least 1 clinical criterion

  •  Radiological criteria
    • Sacroiliitis (grade ≥2 if bilateral)
    • Sacroiliitis (grade ≥3 if unilateral)
  • Clinical criteria
    • Low back pain and stiffness for ≥3 months that improves with exercise, but not relieved by rest
    • Limitation of motion of the lumbar spine in the sagittal and frontal planes
    • Limitation of chest expansion relative to normal values correlated for age and gender

Assessment

  • Therapy of patients with ankylosing spondylitis (AS) should be tailored according to the following:
    • Current manifestations of ankylosing spondylitis (AS) [ie axial, peripheral, entheseal, extra-articular]
    • Level of current symptoms, clinical findings and prognostic indicators
    • General clinical status (ie age and gender, comorbidities, concomitant therapy, psychosocial factors)
  • Frequency of assessments (ie patient history with use of questionnaires, clinical parameters, laboratory tests, imaging) should be decided based on course of symptoms, severity, and treatment

Assessment in SpondyloArthritis international Society (ASAS) Core Set

  • Group of core domains assessed for treatment response and disease activity
  • Includes assessment of function, pain, patient’s global assessment, stiffness, spinal mobility, peripheral joints and entheses, acute phase reactants (APRs), fatigue, and radiographs aided by the following instruments:
    • Physical function: Bath ankylosing spondylitis functional index (BASFI)
    • Pain: Numerical rating scale/visual analogue scale (NRS/VAS) during the past week, of the spine at night, and identified from ankylosing spondylitis (AS)
    • Patient global assessment: Numerical rating scale/visual analogue scale (NRS/VAS) of the past week
    • Spinal mobility: Chest expansion, modified Schober, occiput to wall distance, cervical rotation and lateral spinal flexion or Bath ankylosing spondylitis metrology index (BASMI)
    • Stiffness: Numerical rating scale/visual analogue scale (NRS/VAS) duration of morning stiffness of the spine the past week
    • Peripheral joints and entheses: Number of swollen joints (44 joints count), enthesitis score [eg Maastricht ankylosing spondylitis enthesis score (MASES), Berlin, or San Francisco]
    • Acute phase reactants (APRs): Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
    • Fatigue: Bath ankylosing spondylitis disease activity (BASDAI)
    • Radiographs: Used as a measure of outcome of pharmacotherapy rather than disease activity, includes X-ray of anteroposterior, lateral lumbar, lateral cervical spine, and pelvic area to visualize the sacroiliac joints and hips
Criteria for Response
  • Active ankylosing spondylitis (AS) is defined as ankylosing spondylitis (AS) ≥4 weeks and bath ankylosing spondylitis disease activity (BASDAI) ≥4 as assessed by a rheumatologist
  • Assessment in SpondyloArthritis international Society (ASAS) 20
    • Improvement of ≥20% and  ≥1 unit on a scale of 10 in at least 3 of the following 4 domains: patient global, pain, function, inflammation
    • No worsening of ≥20% and ≥1 unit on a scale of 10 in the remaining domain
  • Assessment in SpondyloArthritis international Society (ASAS) 40
    • Improvement of ≥40% and ≥2 units on a scale of 10 in at least 3 of the following 4 domains: patient global, pain, function, inflammation
    • No worsening at all in remaining domain
  • Assessment in SpondyloArthritis international Society (ASAS) 5/6
    • Improvement of ≥20% in at least 5 of the following 6 domains: patient global, pain, function, inflammation, C-reactive protein (CRP), spinal mobility
  • Assessment in SpondyloArthritis international Society (ASAS) partial remission
    • ≤2 units on a scale of 10 in each of the following 4 domains: patient global, pain, function, inflammation
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