Spondylarthropathy treatment: progress in medical treatment, physical therapy and rehabilitation

The educational needs of patients with undifferentiated spondyloarthritis: Validation of the ENAT questionnaire and needs assessment

OBJECTIVES

The aim of the present study was to validate the Swedish version of the educational needs assessment tool (SwENAT) in undifferentiated spondyloarthritis (USpA) and use it to study the educational needs of patients with USpA.

METHODS

This was a cross-sectional study, recruiting a random sample of patients with USpA from a hospital register in Sweden. Educational needs data were collected, together with disease activity and function indices (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] and Bath Ankylosing Spondylitis Functional Index [BASFI]). Rasch analysis was utilized to evaluate the construct validity, internal consistency and unidimensionality of the SwENAT before studying differences in educational needs between patient subgroups (gender, age and disease severity).

RESULTS

Complete responses were obtained from 77 patients (48 women), with a mean age (standard deviation [SD]) of 50 (12) years, a disease duration of 16 (11) years, a BASDAI score of 4.9 (1.9) and a BASFI score of 3.1 (2.3). The SwENAT satisfied the requirements of the Rasch model (χ² = 11.488; p = 0.119), including strict unidimensionality. Overall, the mean (SD) SwENAT score was 86 (32). Women reported higher needs than men in the domains of pain (mean [SD] 13.1 [6.8] versus 10.1 [6.0]; p = 0.05); movement (mean [SD] 13.0 [5.5] versus 9.9 [5.7]; p = 0.02) and self-help (mean [SD] 17.0 [5.8] versus 14.1 [5.0]; p = 0.03). Higher disease activity (BASDAI >4) was associated with higher educational needs (mean [SD] 92.6 [31.9] versus 73.7 [29.4]; p = 0.02).

CONCLUSIONS

These data suggest that the SwENAT is valid in USpA. Women and patients with higher disease activity are more likely to have high levels of educational needs, so special attention and strategies to target patient education are warranted.

Recommendations for the prescription of physical exercise for patients with spondyloarthritis

OBJECTIVE

To develop expert-based recommendations on physical activity and exercise for patients with spondyloarthritis (SpA).

METHODS

Two discussion groups, one of physical therapists, rehabilitation physicians, and professionals of physical activity and sports, and another of rheumatologists interested in SpA, were held to discuss the results of a survey of rheumatologists on exercise and two focus groups with patients on barriers to exercise. Preliminary recommendations were drafted. These were submitted to the opinion of the experts in both groups according to a two round Delphi methodology.

RESULTS

Twenty one recommendations covering general aspects of exercise, adaptation to patient, how to deliver messages, pain management, and type of exercise and monitoring were issued. The level of agreement varied slightly between expert groups but it was high overall. Items with poor agreement were removed from the consensus.

CONCLUSIONS

We present recommendations on when and how to prescribe and monitor exercise in patients with SpA based on the opinion of experts in exercise and in SpA. We must now test whether these recommendations are useful for clinical practice and have an effect on patients with SpA seen by rheumatologists.

Evaluation of the short-term efficacy of NSAIDs on patients with active ankylosing spondylitis in daily practice: a 3-month, longitudinal, observational study

The objective of the study was to investigate the response rate to non-steroidal anti-inflammatory drugs (NSAIDs) and the clinical parameters that might predict this response in patients with active ankylosing spondylitis. This is a prospective, observational, 3-month study that was conducted in a single center. Ninety-five consecutive patients with active ankylosing spondylitis were included in the study. Full dose NSAIDs (indometacin 150 mg daily or acemetacin [corrected] 180 mg daily) were given to patients. Relevant clinical data of all patients' were recorded at the beginning and on three consecutive monthly visits. At the end of the study period, patients who respond to NSAIDs were determined. Demographic, clinical, and laboratory parameters that might influence the response to the NSAIDs were investigated. The response rate to the full-dose NSAIDs according to the ASAS20 in patients with active ankylosing spondylitis was found as 29.5%. Similarly, 20.0% of the patients were responders according to the ASAS40 criteria, whereas 5.6% of the patients responded according to the 5-out-of-6 criteria at week 12. Patients who responded to the treatment were found to be younger at the study entry (P = 0.001) and had shorter disease duration (P < 0.001). Due to the markedly lower rate of response to the NSAIDs in patients with active ankylosing spondylitis, early identification of those patients who does not respond to NSAIDs and subsequent decision regarding the institution of second-line treatments (anti-TNF) may be of great value in the prevention of irreversible changes that might develop in most of the patients.

Assessments in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease requiring regular medical care and monitoring to alleviate symptoms, maintain function, identify disease progression and initiate appropriate, timely therapies. Monitoring of the AS patient in clinical daily practice should not only include general history taking and physical examination, but also incorporate specific concepts, pertaining to the disease, which will aid in the detection of disease progression, the requirement of therapeutic intervention and the response to therapy. The Assessments in AS (ASAS) international working group has defined a core set of disease concepts that should be a part of everyday clinical record-keeping in AS, and has identified and validated measurement instruments corresponding to these health concepts, which can easily be incorporated into clinical practice. The group has also developed recommendations for management and a consensus statement for the use of biological therapies in AS, which includes recommendations for the monitoring of AS patients receiving these therapies. This chapter reviews the recommendations for monitoring AS patients in daily clinical practice, with particular regard to those receiving biological treatments.

Methotrexate for ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory disease of unknown cause, characterised by sacroiliitis and spondylitis. Generally, treatment is limited to the alleviation of symptoms using non-steroidal anti-inflammatory drugs (NSAIDs). Recently, disease-modifying antirheumatic drugs (DMARDs) have been used for patients for whom NSAIDs do not work. Methotrexate (MTX), a widely used DMARD, is effective for rheumatoid arthritis (RA), and so might work for AS too.

OBJECTIVES

To evaluate the efficacy and toxicity of MTX for treating AS.

SEARCH STRATEGY

We conducted searches in any language in: CENTRAL (The Cochrane Library Issue 4, 2005); MEDLINE (1966 to November 20, 2005); EMBASE (1980 to November 20, 2005); CINAHL (1982 to November 20, 2005), and the reference sections of retrieved articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials examining the efficacy of MTX versus placebo, other medication, or no medication, for AS.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed unblinded trial reports for inclusion, assessed methodological quality and entered trial data into RevMan 4.2 using the double-entry facility. Disagreements were resolved by a third reviewer. In the absence of significant heterogeneity, results for continuous data were combined using weighted mean difference or standardised mean difference. Relative risk was used for dichotomous data.

MAIN RESULTS

Three trials, involving 116 patients, were included. One 12-month trial compared naproxen plus MTX with naproxen alone. Two 24-week trials compared different doses of MTX with placebo. No statistically significant differences were found for the primary outcome measures of physical function, pain, spinal mobility, peripheral joints/entheses pain, swelling and tenderness, changes in spine radiographs and patient and physician global assessment. Only the response rate in one trial showed a statistically significant benefit of 36% in the MTX group compared to the placebo group (RR 3.18, 95% CI 1.03 to 9.79). This response rate was a composite index that included assessments of morning stiffness, physical well-being, Bath ankylosing spondylitis disease activity index (BASDAI), Bath ankylosing spondylitis functional index (BASFI), health assessment questionnaire for spondyloarthropathies (HAQ-S), and physician and patient global assessment. However, no single outcome showed a statistically significant difference between the MTX and placebo groups when endpoint results were compared. Therefore, this benefit of MTX is questionable. No serious side effects were reported in these trials.

AUTHORS' CONCLUSIONS

There is not enough evidence to support any benefit of MTX in the treatment of AS. High-quality randomised controlled trials of longer durations and with larger sample sizes are needed to clarify the effect(s) of MTX on AS.

The role of nonsteroidal anti-inflammatory medications and exercise in the treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic systemic rheumatic disease that primarily affects the sacroiliac joints and spine. Even with the development of tumor necrosis factor-alpha inhibitors, which have revolutionized the treatment of this disease, the combination of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and a life-long exercise program still form the first step in its management. Multiple clinical trials have addressed the efficacy and safety of both nonselective and selective NSAIDs. Gastrointestinal toxicity remains their major side effect, with increased concern about the potential of cardiovascular toxicity, especially with the selective cyclooxygenase-2 inhibitors. A specific set of recommendations has been proposed for the management of AS.

Nonsteroidal anti-inflammatory drug use in ankylosing spondylitis—a population-based survey

The objective of the study is to describe the use, clinical efficacy, and toxicity of nonsteroidal anti-inflammatory drug (NSAID) therapy in patients with ankylosing spondylitis (AS). A cross-sectional population study of 1,080 AS patients was carried out by a written questionnaire in the year 2000. Seventy-eight percent of AS patients had regularly taken NSAIDs for their disease 12 months prior to the study. Most AS patients commonly used diclofenac, naproxen and indomethacin. AS patients were generally rather satisfied with the efficacy of their therapy where 19.1% reported complete pain control, 26.8% reported pain reduction to one quarter, and a further 34.4% reported pain reduction to one half. However, over 20% of patients taking NSAIDs still reported insufficient pain control and more than 40% changed the NSAID due to lack of efficacy. One quarter of AS patients reported severe side effects from their treatment, most commonly abdominal pain, headache and dizziness, and nausea. There was no effect on age or duration of disease on the occurrence of NSAID-related side effects. Medications were commonly ceased or changed due to inefficacy or side effects. The percentage of AS patients reporting changing their NSAID due to side effects ranged from 10.5% for celecoxib to 31.4% for indomethacin. We conclude that NSAIDs are effective in the management of inflammatory symptoms of many, but not all, patients with AS. There is a significant side effect profile, which frequently results in medication change or cessation. Anti-tumor necrosis factor therapy may reduce the need for intensive long-term NSAID therapy in AS.

Magnetic resonance imaging guided corticosteroid injection of sacroiliac joints in patients with spondylarthropathy. Are multiple injections more beneficial?

Efficacy of a second magnetic resonance (MR) imaging guided corticosteroid injection of inflamed sacroiliac joints (SIJ) in patients with spondylarthropathy. Thirty-one patients received 50 injections in an outpatient basis. Fifteen of 31 patients who relapsed or were non-responders received a second injection. All had MR guided injection of 40 mg triamcinolone acetonide into SIJ using an open 0.2 Tesla unit. Twenty of 31 patients after the first injection, and 9 of 15 patients after the second injection reported subjective improvement, which lasted for a mean of 8.7+/-10.9 and 16.1+/-15.8 months for each group. Subchondral bone marrow edema resolved in 15 of 20 patients who reported subjective improvement, after the first injection. No complications occurred. MR guided steroid injection of SIJ is effective and safe. Since there is no exposure to radiation it could be performed many times. Repeated injections seem to be beneficial for primary non-responders and patients who relapsed.

Sulfasalazine for ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory disease of unknown cause and belongs to a group of diseases known as spondyloarthropathies (SpA), which includes reactive arthritis, arthritis/spondylitis in inflammatory bowel disease, psoriatic arthritis/spondylitis and undifferentiated SpA. Non-steroidal anti-inflammatory drugs (NSAIDs) have been the main treatment for AS. For those refractory or intolerant to NSAIDs, the disease modifying antirheumatic drugs (DMARDs) have been used as a second line approach. Sulfasalazine (SSZ) is the best studied DMARD in AS, but its efficacy remains unclear.

OBJECTIVES

To evaluate the efficacy and toxicity of sulfasalazine for the treatment of ankylosing spondylitis.

SEARCH STRATEGY

Relevant randomised and quasi-randomised trials in any language were sought using the following sources: CENTRAL (Cochrane Central Register of Controlled Trials, Issue 2, 2003), MEDLINE (1966 to June Week 4 2003), EMBASE (1980 to 2003 Week 26), CINAHL (1982 to June Week 3 2003) and the reference section of retrieved articles.

SELECTION CRITERIA

We evaluated randomised and quasi-randomised trials examining the efficacy of sulfasalazine on ankylosing spondylitis.

DATA COLLECTION AND ANALYSIS

Unblinded trial reports were reviewed independently by two reviewers according to the selection criteria. Disagreements on the inclusion of the studies were resolved, where necessary, by recourse to a third reviewer. The methodological quality of included trials were independently assessed by the same reviewers on randomization, concealment, blindness (participants, care providers and outcome investigators), description of withdrawals and drop-outs and intention-to-treat analysis. The same reviewers independently entered the data extracted from the included trials, using RevMan double entry facility. Results were combined using weighted mean difference or standardised mean difference for continuous data, and relative risk for dichotomous data.

MAIN RESULTS

Twelve studies met the inclusion criteria but only eleven were included in the data analysis. The pooled analysis showed that the difference between intervention groups was significant only in erythrocyte sedimentation rate (ESR) (WMD -4.79, 95% CI -8.80 to -0.78) mm/h) and morning stiffness VAS-100 mm (visual analogue scale 100 mm, where 0 = no stiffness and 100 = severe) (WMD -13.89, 95% CI -22.54 to -5.24), favouring SSZ over placebo. The trial with the largest sample (Clegg 1996) and that with the longest treatment duration (Kirwan 1993) had similar results. Both trials found that SSZ showed evidence of benefit in the occurrence of peripheral joint symptoms and peripheral responses in patients with peripheral arthritis. Nissila 1988 is the only trial in which SSZ showed benefit in primary outcome analyses, including back pain, chest expansion, occiput-to-wall test and patient's general well being. Compared with other trials, the patients in this trial had the shortest disease duration and the highest level of baseline ESR and contained the greatest proportion of patients with peripheral arthritis. Significantly more withdrawals for side effects (RR 1.50, 95% CI 1.04 to 2.15, NNH 23, 95% CI 10 to 288) and for any reason (RR 1.33, 95% CI 1.03 to 1.73, NNH 17, 95% CI 8 to 180) were found in SSZ compared with placebo group although severe side effects were rare (1 of the 469 patients taking SSZ).

AUTHORS' CONCLUSIONS

Across all AS patients, SSZ demonstrated some benefit in reducing ESR and easing morning stiffness, but no evidence of benefit in physical function, pain, spinal mobility, enthesitis, patient and physician global assessment. Patients at early disease stage, with higher level of ESR (or active disease) and peripheral arthritis might benefit from SSZ.

Health status of patients with ankylosing spondylitis: a comparison with the general population

OBJECTIVE

To examine the subjective health in patients with ankylosing spondylitis (AS) compared with the general population, and to explore the associations between health status and age, sex of the patients, and educational level in AS.

METHODS

Health status was assessed with a generic instrument (SF-36) in 314 patients with AS and in 2323 people from the general population. Subgroup analyses were performed according to age, sex, and educational level. Standard difference scores (s-scores) were calculated to ensure the clinical meaningfulness of the norm based comparisons.

RESULTS

Both men and women with AS reported significantly impaired health on all scales of the SF-36. Women reported significantly worse health on physical health domains. However, when calculating differences from the general population, numerically larger s-scores were found for men (except for physical role and vitality). The relative impact of AS seems to diminish with increasing age. In AS, better health was significantly associated with higher education across all scales. Deviations from the general population on the non-physical health aspects were especially pronounced in patients with low education.

CONCLUSIONS

All key dimensions of health are affected by AS. The physical aspects seem to be most severely affected, but in the less educated group of patients, the disease impact on the mental health aspects was also considerable. Evaluation and management planning should take the complexity of AS into consideration. The focus on physical function should be maintained, and additional attention should be paid to the mental and social consequences of AS.

Chlamydia-induced arthritis

PURPOSE OF REVIEW

Chlamydia-induced arthritis is the most frequent form of reactive arthritis in Western countries. This article gives an overview of the recent findings with respect to diagnosis, pathogenesis, and therapy of the disease.

RECENT FINDINGS

Recent advances in the modification and standardization of polymerase chain reaction techniques give promise to identify Chlamydia more frequently from joint samples. Based on the sequenced chlamydial genome, considerable progress has been achieved in the understanding of the Chlamydia-host cell interaction, indicating that persistence is an alternate state of the bacteria used by Chlamydia to escape the immune system of the host rather than a general stress response. Furthermore, Chlamydia has the ability to reprogram the host cell by chlamydial effector proteins, which are transported from the inclusion into the host cell cytoplasm. The role of HLA-B27 is discussed in view of the pathogenesis of the disease. HLA-B27 should be considered a risk factor for chronic and/or axial disease rather than a true susceptibility factor for the development of Chlamydia-induced arthritis. No progress has been made in terms of causative therapy aiming at eradication of the bacteria. Tumor necrosis factor-alpha blocking agents may represent a new option in cases that are refractory to therapy.

SUMMARY

Molecular biology not only has improved the ability to detect Chlamydia in the joint for diagnostic purposes but also has extended the current understanding of the pathogenesis of the disease. In contrast to this progress, causative therapy of Chlamydia-induced arthritis is still an unfulfilled need.

Methotrexate for ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory disease of unknown cause, characterized by sacroiliitis and spondylitis. To date, treatment of AS has been limited to the alleviation of symptoms, mainly using non-steroidal anti-inflammatory drugs (NSAIDs). For patients refractory or intolerant to NSAIDs, the disease modifying antirheumatic drugs (DMARDs) have been used as a second line approach. Methotrexate (MTX) is currently one of the most widely used DMARDs and its efficacy in rheumatoid arthritis (RA) has been confirmed (Suarez-Almazor 2003). There is uncertainty whether MTX works in the treatment of AS.

OBJECTIVES

To evaluate the efficacy and toxicity of methotrexate in the treatment of ankylosing spondylitis.

SEARCH STRATEGY

Relevant randomised and quasi-randomised trials in any language were sought using the following sources: CENTRAL (Cochrane Central Register of Controlled Trials, Issue 2, 2003), MEDLINE (1966 to June Week 4 2003), EMBASE (1980 to 2003 Week 26), CINAHL (1982 to June Week 3 2003) and the reference section of retrieved articles.

SELECTION CRITERIA

We evaluated randomised and quasi-randomised trials examining the efficacy of methotrexate on AS.

DATA COLLECTION AND ANALYSIS

Unblinded trial reports were reviewed independently by two reviewers according to the selection criteria. Disagreements on the inclusion of the studies were resolved, where necessary, by recourse to a third reviewer. The methodological quality of included trials were independently assessed by the same reviewers on randomization, concealment, blindness (participants, care providers and outcome investigators), description of withdrawals and drop-outs and intention-to-treat analysis. The same reviewers independently entered the data extracted from the included trials, using RevMan's double entry facility. In the absence of significant heterogeneity, results were combined using weighted mean difference or standardised mean difference for continuous data, and relative risk for dichotomous data.

MAIN RESULTS

Two trials met the inclusion criteria. Altan 2001compared naproxen plus MTX (7.5 mg/week orally) with naproxen alone and Roychowdhury 2002 compared MTX (10 mg/week orally) with placebo. The duration of the trials were 12 months and 24 weeks, respectively. They assessed different outcomes except for C-reactive protein (CRP). The included trials treated a total of 81 patients and assessed more than 10 outcomes relevant to the review, covering function, pain, peripheral arthritis/enthesitis, morning stiffness, patient and physician global assessment, CRP and erythrocyte sedimentation rate (ESR). No significant difference between intervention groups was found favouring MTX over no MTX. No serious side effect was reported in either trial.

REVIEWERS' CONCLUSIONS

There was no statistically significant benefit of MTX in the examined outcomes for AS patients. High quality, larger sample and longer period of randomized controlled trials (possibly with higher dosage of MTX) are needed to verify the uncertainty about the efficacy and toxicity of MTX for the treatment of AS.

Diagnosis and treatment of enthesitis

The conceptual understanding of SpA and the ability to image sites of skeletal inflammation accurately and confirm that enthesitis is the primary lesion has occurred around the same time as the greatest therapeutic advances in AS and SpA with the advent of potent anti-TNF therapies for enthesitis. These therapies have transformed the understanding of enthesitis and revolutionized therapy of what was often an intractable problem. Now that clinicians better understand enthesitis-related disease mechanisms and have the ability to image them in early disease and monitor them, there is an urgent need to assess optimal conventional drug therapy in these conditions.

Ankylosing spondylitis: an overview

Ankylosing spondylitis (AS) is a complex, potentially debilitating disease that is insidious in onset, progressing to radiological sacroiliitis over several years. Patients with symptomatic AS lose productivity owing to work disability and unemployment, have a substantial use of healthcare resources, and reduced quality of life. The pathogenesis of AS is poorly understood. However, immune mediated mechanisms involving human leucocyte antigen (HLA)-B27, inflammatory cellular infiltrates, cytokines (for example, tumour necrosis factor alpha and interleukin 10), and genetic and environmental factors are thought to have key roles. The detection of sacroiliitis by radiography, magnetic resonance imaging, or computed tomography in the presence of clinical manifestations is diagnostic for AS, although the presence of inflammatory back pain plus at least two other typical features of spondyloarthropathy (for example, enthesitis and uveitis) is highly predictive of early AS. Non-steroidal anti-inflammatory drugs (NSAIDs) effectively relieve inflammatory symptoms and are presently first line drug treatment. However, NSAID treatment has only a symptomatic effect and probably does not alter the disease course. For symptoms refractory to NSAIDs, second line treatments, including corticosteroids and various disease modifying antirheumatic drugs, are employed but are of limited benefit. Emerging biological therapies target the inflammatory processes underlying AS, and thus, may favourably alter the disease process, in addition to providing symptom relief.

Conventional treatments for ankylosing spondylitis

Management of ankylosing spondylitis (AS) is challenged by the progressive nature of the disease. To date, no intervention is available that alters the underlying mechanism of inflammation in AS. Currently available conventional treatments are palliative at best, and often fail to control symptoms in the long term. Current drug treatment may perhaps induce a spurious state of "disease remission," which is merely a low level of disease activity. Non-steroidal anti-inflammatory drugs are first line treatment, but over time, the disease often becomes refractory to these agents. Disease modifying antirheumatic drugs are second line treatment and may offer some clinical benefit. However, conclusive evidence of the efficacy of these drugs from large placebo controlled trials is lacking. Additionally, these drugs can cause treatment-limiting adverse effects. Intra-articular corticosteroid injection guided by arthrography, computed tomography, or magnetic resonance imaging is an effective means of reducing inflammatory back pain, but controlled studies are lacking. A controlled study has confirmed moderate but significant efficacy of intravenous bisphosphonate (pamidronate) treatment in patients with AS; further evaluation of bisphosphonate treatment is warranted. Physical therapy and exercise are necessary adjuncts to pharmacotherapy; however, the paucity of controlled data makes it difficult to identify the best way to administer these interventions. Surgical intervention may be required to support severe structural damage. Thus, for patients with AS, the future of successful treatment lies in the development of pharmacological agents capable of both altering the disease course through intervention at sites of disease pathogenesis, and controlling symptoms.

Building consensus on nomenclature and disease classification for ankylosing spondylitis: results and discussion of a questionnaire prepared for the International Workshop on New Treatment Strategies in Ankylosing Spondylitis, Berlin, Germany, 18-19 January 2002

BACKGROUND

There is currently no universal consensus on nomenclature for spondyloarthropathy (SpA), or on activity and severity criteria for ankylosing spondylitis (AS).

METHOD

Points of agreement and majority opinions among 28 international experts in the field were identified by questionnaire. Agreement was defined as >80% concurrence, clear majority as >60% concurrence, and a majority or trend as >50% concurrence.

RESULTS

Respondents agreed on the need for one term that reflects the inflammatory nature of the disease, but no agreement was reached on a specific term. Agreement included subdivision of patients with SpA into AS, psoriatic arthritis, inflammatory bowel disease associated arthritis, and undifferentiated spondyloarthritis/spondyloarthropathy. A majority of experts defined active disease as fulfilling classification criteria for AS and/or a SpA, and disease activity measured by a Bath AS Disease Activity Index (BASDAI) score >4 determined by two patient visits during a two month period, but no maximum radiographic score. The majority of participants considered failure of treatment response to non-steroidal anti-inflammatory drugs (NSAIDs) alone to be a prerequisite for active/severe AS, and 15/28 (54%) thought that NSAID treatment failure should be defined as lack of response to two or more NSAIDs.

CONCLUSIONS

Respondents agreed that a two to five year study is the ethical method to demonstrate effects of anti-tumour necrosis factor alpha (TNFalpha) therapy on radiographic progression of AS, and that inclusion criteria should include a certain level of disease activity (measured by BASDAI) and failure of certain treatments. After the efficacy of anti-TNFalpha therapy in AS and psoriatic arthritis is proved, respondents agreed that more studies will be needed to show efficacy for other SpA subsets.

Treatment of spondyloarthropathies. Recent advances and prospects in 2001

The management of patients with spondyloarthropathy is undergoing radical changes in several areas and for several reasons. The main reason seems to be improved awareness of the fairly high prevalence of this group of disorders, which is close to that of rheumatoid arthritis. Evaluation of the various treatment modalities has benefited from work by the international Assessment in Ankylosing Spondylitis group (ASAS) group aimed at developing standardized evaluation criteria. Controlled treatment trials have provided useful information on non-pharmacological treatments such as physical exercise programs and patient information. Nonsteroidal anti-inflammatory drugs (NSAIDs) remain the cornerstone of the pharmacological treatment. Recent studies have shown that NSAIDs capable of selectively inhibiting type 2 cyclooxygenase have a better gastrointestinal safety profile and are as effective in relieving clinical symptoms as conventional NSAIDs. Importantly, maintenance treatment seems effective not only on peripheral joint manifestations but also on axial manifestations that fail to respond to NSAIDs. Thalidomide and TNF antagonists are promising maintenance agents.

First manifestations of seronegative spondylarthropathy following autologous stem cell transplantation in HLA-B27-positive patients

Two male patients with non-Hodgkin's lymphoma (NHL, follicular NHL, diffuse large B cell NHL, both in 2nd complete remission) and one female patient with acute myeloid leukemia in 1st complete remission developed arthralgias and enthesopathy following autologous stem cell transplantation. In 2/3 patients, sacroiliitis could be demonstrated on X-ray. In both patients, the rheumatic symptoms were classified as manifestations of a spondylarthropathy. All three patients were subsequently shown to be HLA-B27-positive. The patients were successfully treated with non-steroidal anti-inflammatory drugs. The differential diagnosis of joint pain following autologous stem cell transplantation should include HLA-B27-associated spondylarthropathies in addition to the more commonly seen bone and joint pain due to immobilization and medication.