Treating SpA to target
Dr. Adriana Ramona Valea, Dr. Shawn Chavrimootoo, Dr. SA Ramakrishnan
Rheumatology Department, Our Lady's Hospital, Navan, Co Meath
Spondyloarthritis (SpA) is a chronic inflammatory disease involving the spine and peripheral joints, with possible extra-articular manifestations such as uveitis, psoriasis and bowel inflammation. The treatment goals are maintenance of physical function, control of disease activity and prevention of radiographic progression.
The "treat to target" concept is based on having clearly identified goals for guiding therapy. It is implemented in many areas of medicine and specifically in rheumatology it has proven to be successful for Rheumatoid arthritis and Gout.
The aim of the audit was to compare our clinical practice in Rheumatology Department in Our Lady's Hospital Navan to the international ASAS recommendations for the use of anti-TNF agents in patients with SpA.
In our Department we enroll all patients with established SpA diagnosis in a Treat to Target Programme where they are followed-up 6 weekly and therapy is conducted as per ASAS guidelines until achieving remission.
We performed a retrospective analysis of 29 charts of patients diagnosed with SpA between January and December 2016 that have attended Physiotherapy Programme and registered data on duration of symptoms before presentation, diagnosis and type of joint involvement and extraarticular manifestations, initial NSAID therapy and subsequent DMARD or TNF therapy when appropriate.
In this group, 38% were male patients and 62% were female, with a mean age of 35 yrs and mean duration of low back pain 5 yrs. 82.7% had been diagnosed with axial SpA out of which one had psoriatic arthritis for the last 5yrs, and 17.3% were diagnosed with axial and peripheral SpA out of which one had IBD. In the group with peripheral involvement there were 4 cases of uveitis, 2 of enthesitis and 1 dactylitis.
Sacroiliitis was confirmed on MRI in 68.9%, on x-ray in 17.2% and 13.7% were diagnosed on HLA pathway. HLA B27 was found positive in 62% of all patients.
All patient with the exception of IBD case were started on NSAIDs after diagnosis and re-assessed by the rheumatology nurse 6 weekly for escalation of therapy to second NSAID and TNF inhibitor as needed. Out of 5 patients with peripheral involvement 3 were started on Salazopyrine after diagnosis and are still on it along with TNF therapy after failure to control symptoms, 1 refused DMARDs or TNF and IBD pt started on TNF therapy from diagnosis. Once achieving remission patients were offered outpatient appointment.
At present in this patient group 14 pt (48.2%) are still controlled with NSAIDs ( 7 on first NSAID and 7 on second, 13 pt (44.8%) are on TNF inhibitor (6 on the first one and 7 on the second one) with 2 patients offered TNF and refused.
In all 29 patients diagnosed with SpA the ASAS guidelines for management were correctly implemented
ASAS guidelines recommend using the BASDAI score for assessing disease activity. In our clinical practice ASDAS-CRP score is used for this purpose. The ASAS guidelines were initially developed before the development of ASDAS-CRP score and it is not yet included in the guidelines though it had proven a longitudinal relationship with subsequent syndesmophyte formation that BASDAI score is lacking.