Spondylitis Association of America 20 Years of Setting the Course

1. Organizational Meeting for the AS-US Working GroupAdvancing Clinical Researchin AS and SpA in the USA Spondylitis Association of America 20 Years of Setting the Course

2. Concluding Remarks Muhammad Asim Khan, MD, MACP, FRCP Professor of Medicine Case Western Reserve University Cleveland, Ohio, USA

3. The Spondyloarthropathies Ankylosing Spondylitis Juvenile SpA Psoriatic Arthritis Undiff SpA Reactive arthritis Arthritis associated with Ulcerative colitis Crohn’s dis

4. 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

5. Prevalence of PsA No population-based US study

6. 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 JT, Husby G, Hordvik M. Ann Rheum Dis 1985; 44: 359-67. 2 Riise et al. J Rheumatol 2000; 27: 1386-9.

7. Spondyloarthropathies ESSG Criteria 7 Dougados M, et al. Arthritis Rheum. 1991 Oct;34(10):1218-1227.

8. Spondyloarthropathies Amor Criteria 1990 8 Amor B, et al. Rev Rheum Mal Osteoartic. 1990;57:85-89.

9. Prevalence of AS & Related SpA (%) 10 Adapted with permission from Khan MA. Ann Intern Med. 2002;136:896-907.

10. Sacroillitis: Most Common Among The Spondyloarthropathies Ankylosing Spondylitis Juvenile SpA Psoriatic Arthritis Entheitis Sacroiliitis Synovitis Undiff SpA Reactive arthritis Reiter syndrome Arthritis associated with Ulcerative colitis Crohn’s dis

11. ENTHESITIS

12. ENTHESIS • Compact fiber bundles region • Fibrocartilage, non-mineralized • Mineralized fibrocartilage • Lamellar bone Braun, Khan, Sieper. ARD 2000; 59: 985-94

13. 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). (Courtesy of M. Rudwaleit and J. Sieper.) b) 5 minutes after gadolinium inj.

14. Khan MA: In: Hochberg et al. RHEUMATOLOGY, (3rd Ed.) 2003, (in press).

15. How to make an early diagnosis? Probability of AS/Axial SpA in Patients With Back Pain Underwood & Dawson Brit J Rheumatol 1995. Chronic Back Pain 5% Inflammatory Back Pain 14% Any one of the additional clinical features: e.g. enthesitis, positive family history, uveitis, asymmetric arthritis, positive response to NSAIDs, etc. 30-70% Imaging = X-rays If negative, then CT or MRI (or HLA-B27) 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.

16. HLA B27 Distribution 25 24 30 16 40 19-34 40 8 50 HLA B2709 HLA B2706 0 0 0 Khan MA. Current Opin Rheumatol 1995;7:263-269.

17. Noncompliance: The Other “Drug Problem” Rates of non-compliance with arthritis therapy ranges from 22% to 75% Maetzel et al. Rheumatology 2000; 39:975.

18. 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.

19. 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

20. 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.

21. 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.

22. 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