Managing Complications for Spondylitis Patients

Managing Complications for Spondylitis Patients


OK. So what I’m going to try to address for you today, this is just an outline… is what can be affected besides the joints in your body when it comes to spondylitis. And different from many diseases… In fact, this is true with regards to many rheumatologic diseases… These are systemic diseases. So they affect the whole body. Though the most common place they go is the joints or the spine or the sacroiliac joints… Other parts of the body can be affected. I’ll address what the long term complications are and why they occur in patients…. And what you can do to help screen and prevent these complications. For the purpose of the talk I will use the term ankylosing spondylitis. We’re going to sort of say this is analogous to spondyloarthritis. Although ankylosing spondylitis is a type of spondyloarthritis… Really, anyone within this entire family can have any of these manifestations or complications. So, if you just think about the organ systems that can be affected besides the joints… These are the three major ones: the eye, the skin and the gut, the gastrointestinal system. We’re going to go through each of these individually. So, first the eye and the reason I start with the eye is because… Eye inflammation is probably the most common non-joint manifestation that can affect patients with ankylosing spondylitis. And this is in the form of something called uveitis or iritis, typically affecting the anterior chamber. So, this is an anatomy of an eye, and if you’ve had iritis before… Which many patients have, then you may not realize actually where the inflammation is. So my cursor is pointing to the anterior chamber. That’s the chamber of fluid that is in front of the lens of the eye. That is most commonly where inflammation happens in this disease. It’s the most common non-joint manifestation… Affecting somewhere between 25 to 40 percent of ankylosing spondylitis patients at some point in their disease course… And it could be the presenting manifestation, but it could also happen after the diagnosis of the arthritis. It’s particularly more common in patients that are HLA- B27 positive. So if you have AS and you’re B27 negative, it is far less likely that you will develop this complication. The symptoms and signs to watch out for are usually one side of the eye is affected. The light is really bothersome to patients. We call this photophobia. There is often pain when you change focus. So when you think about a camera changing the focus of a lens… When you look from far to near, that is quite painful. Patients can have red eyes as well. you can see on the left side, here is a patient with active iritis or uveitis. You can see the redness of the eye and then you can actually see a layer of white fluid that’s collected at the bottom. That’s pus, so those are white blood cells in the front part of the chamber of the eye. This is iritis or uveitis. So the treatment for this complication is actually quite simple as long as it’s identified early. That is steroid drops in the eye. Sometimes we will also use dilating drops to dilate the eye and that helps with the pain. Though, if it’s not treated promptly and certainly if patients develop chronic uveitis… Then they may require either an injection of steroids to the eye or even oral or injectable medicines. If you’ve had uveitis before, multiple times, then you should actually have drops at home prescribed to you by your rheumatologist or your ophthalmologist… So that you can initiate prompt treatment of active iritis and then follow up immediately with an ophthalmologist. This is really important. We know that patients recognize when they have iritis, in fact, more so than a rheumatologist would. So if you’re at home on a Saturday morning and you realize that your eye is flaring… You should have those drops to start and you should have an appointment quickly the next week with an ophthalmologist… To make sure that you actually do have it and that you can taper the steroids properly. So gut inflammation is also quite common in ankylosing spondylitis, and there are different forms of gut inflammation. So the classic very obvious form of inflammation is in the setting of Crohn’s disease and ulcerative colitis. You can also get a limited form of ulcerative colitis called ulcerative proctitis and this is inflammation of the small or large bowel or both. So with regards to Crohn’s disease, you can have inflammation anywhere from the mouth all the way down to the anus. And some people only have it in the small bowel and some people have it only in the large bowel and some people have both. Ulcerative colitis is limited to the colon. In fact, there is no inflammation outside of the large bowel. And these are the patients that sometimes get a colectomy and then everything from a gastrointestinal standpoint, resolves. That said, many patients with ankylosing spondylitis have inflammation of the gut even without symptoms. There was a recent presentation at our national meeting last year showing that even patients without any gastrointestinal symptoms… That underwent camera endoscopy, where you swallow a small camera, had inflammation of the small bowel. We don’t know what to do with this microscopic inflammation where people don’t have symptoms. There are certain types that are more likely to become full blown Crohn’s disease or ulcerative colitis. But for right now, what we know is that a portion of patients with AS have real Crohn’s disease and ulcerative colitis that needs treatment in its own right. And then a larger portion of patients have some inflammation without overt Crohn’s disease or ulcerative colitis. The symptoms of gut inflammation when it’s really in the setting of Crohn’s disease or ulcerative colitis is often bloody stools and diarrhea. Patients can have abdominal pain and even can present with just weight loss without the overt bloody stools or diarrhea. Now there is a very strong connection with the bacteria in your gut and ankylosing spondylitis. And we don’t know exactly what those bacteria are doing and whether they’re causing the disease or whether they are just there because your joints are inflamed. That is being studied right now. We know that about 5 to 10 percent of patients with ankylosing spondylitis have Crohn’s disease or ulcerative colitis. And if you do the colonoscopy or camera endoscopy, as I mentioned, up to 60 percent of patients will have subclinical gut inflammation. That’s inflammation without symptoms. Now if you do have active ankylosing spondylitis and you also have inflammatory bowel disease… And your doctor is going to put you on a biologic agent for your ankylosing spondylitis… The recommendation would be that you use a certain kind of biologic and those are the ones listed here on the slide In parentheses is the brand name, though we typically will use the generic name. So Adalimumab is Humira, Certolizumab is Cimzia, Golimumab is Simponi and Infliximab is Remicaid. Those are the ones that work for both inflammatory bowel disease and ankylosing spondylitis. The third manifestation outside of the joints that can affect patients with this disease is skin involvement. And that is in the setting of psoriasis. So psoriasis is not an uncommon manifestation in the general population even without AS. It affects somewhere between 2 and 3 percent of the general population. But if you look at patients with ankylosing spondylitis, 10 percent of them will have psoriasis, much more common. The symptoms of psoriasis are often an itchy, flakey, scaly rash that has a red base with a scale on top. So you can see this is actually a very common place for it. It’s behind the ear on the scalp line. And you can see that it’s red and on top of the redness is a thick plaque or scale. That’s psoriasis. The treatment for psoriasis can be in the setting of just topical steroids. So using a cream or an ointment that’s a steroid on top of the lesions usually works quite well. But sometimes patients have it severely enough that they require oral medicines or biologics. And similar to inflammatory bowel disease, many of the same medications that work for ankylosing spondylitis also work for psoriasis. Now you might be thinking, why is it such bad luck that I would have psoriasis, inflammatory bowel disease and ankylosing spondylitis? And this slide shows the genetics of these three diseases. So the top line is the genetics – and this is from an older study, it was 2012. We’ve learned a lot more even since then, but even in 2012, you can see these are the genes that are risk genes for ankylosing spondylitis The second line is psoriasis and psoriatic arthritis and the third line is inflammatory bowel disease. And you can see how many common genes there are to all three diseases. So patients that are at risk for ankylosing spondylitis will have the same genes… That will put them at risk for psoriasis, psoriatic arthritis and inflammatory bowel disease. That’s why so many people have all three manifestations. Now, there are other organs that can rarely be involved in ankylosing spondylitis. So it can very rarely affect the lungs and you can get some fibrosis at the top of the lungs here. That is quite rare and it’s also not usually symptomatic. So patients don’t usually have any pulmonary or lung symptoms with regards to this. In the old literature, about 60 years ago… There was a description of the aorta, which is the big vessel that comes out of the heart and feeds the rest of the body… Having inflammation and in fact, the aortic valve becoming incompetent and often needing to be replaced. Now we are actually studying that right now to see if that’s true in this day and age… Or whether potentially the literature that was published 60 years ago was biased. We are not seeing the same high proportion of inflammation as was shown that many years ago. So we can talk about why that is, but it may be that this is not so common as what was once thought. The kidneys also can very, very rarely be affected. So amyloidosis is a type of protein that’s deposited in the kidneys. This happens in the setting of having chronic inflammation. And we used to see this more in patients with rheumatologic diseases because we had no way of controlling the inflammation. So nowadays, that we have good therapies to control the inflammation, we rarely see amyloidosis. IGA nephropathy is also a rare complication or another disease that can happen, but so rare that I am not going to talk about it unless people have questions. Co-morbidities, so what are co-morbidities? You may have heard this from your rheumatologist or from doctors, but I thought, let’s just start with how the Oxford dictionary defines it. Co-morbidity is a noun and basically reflects the simultaneous presence of two chronic diseases in the same patient. So, an example that the Oxford dictionary gives is the comorbidity of anxiety and depression in Parkinson’s disease. Now the anxiety and depression are not directly caused by the Parkinson’s but they’re indirectly associated with it. What I would say is that you could replace Parkinson’s with ankylosing spondylitis… And say that probably any disease that is chronic may be associated with more depression. Having to deal with a chronic disease every day is hard for many patients… And so you can understand why the comorbidity of anxiety and depression may also happen… In someone with ankylosing spondylitis. So why do comorbidities happen? The first comment I’ll make is, well, they happen more in people with chronic disease. And again, depression is the example there. So, you know, I think we’re very good as doctors telling you what your disease is… And even fixing your disease early on and treating the inflammation… But what we don’t do as well, especially early in the course of diagnosing someone… Is sort of arm them with the weapon they need to fight the fact that they’re going to have a chronic disease… And need to deal with this on a daily basis, and it’s almost like having a full time job. And so that often comes up later in the course as I’m seeing patients. But just to acknowledge that having this kind of arthritis is something that you’ll end up dealing with on a daily basis… That can be very difficult. So why do people develop these complications that I described in terms of heart and lung? That’s often because people have had longstanding inflammation. And it’s really the inflammation that is the risk for having some of these complications. So we know that patients that have had a lot of inflammation from their AS… Will then also develop fusion and ankylosis of the spine and this may be associated with fracture. So early in disease when there’s inflammation, actually patients lose bone. And they can develop osteoporosis, which is also a risk for fracture. Later they fuse their spine. And then, of course, you’ve got a weak bone that you’ve fused and that’s a high risk for fracture. So, we’ll talk about how facture is a complication in relation to longstanding ankylosing spondylitis. Another example of co-morbidity would be heart disease. Patients with ankylosing spondylitis can have more ischemic heart disease or coronary artery disease. And we think that this is a result of chronic inflammation. We see this in other rheumatic diseases too. For example, rheumatoid arthritis patients and lupus patients also have more coronary artery disease. And we think that this is related to inflammation. In fact, in rheumatoid arthritis it’s been shown that when you treat the inflammation you decrease the risk of some of this heart disease. So these are the other non-joint comorbodities. Another non-joint co-morbidity is restrictive lung disease. Restrictive lung disease means that in ankylosing spondylitis the chest wall does not expand properly… Because of the fusion of the thoracic spine. If the spine is fused then you cannot expand your thoracic cavity when you take a deep breath. And that often leads to restrictive lung disease. We see more sleep apnea in patients with ankylosing spondylitis and with different risk factors. So if you look at the general population, obstructive sleep apnea is very common in patients that are obese. In ankylosing spondylitis, obesity is not as much of a risk factor. And it’s unclear why this happens compared to the patients without AS. I talked about coronary artery disease related to inflammation. And similar to that, stroke, can happen in the brain. So osteoporosis is thinning of the bones. And this is probably an early manifestation if there’s a lot of inflammation. Down the road, patients can develop fractures related to this and other risk factors.

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