Low back pain is a very common and serious complaint - PDF Document

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  1. Low back pain is a very common and serious complaint

  2. Prevalence of low back pain in the U.S. • 75% of adults sometime in their life time • 50% of adults within the past year Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part IIA&R 2008  

  3. Most acute low back pain improve without treatment • Pain decrease rapidly in within one month in 75- 90% of patients • Pain continues to decrease but more slowly until three months • pain lasting > 3 - 6 months = 5 – 20% PAIN DISABILITY 3 months Pooled from 4,450 publications, BMJ June 4, 2007 Manchikanti et al. Pain Physician 12:E35, 2009 Chou et al. JAMA 303:1295, 2010

  4. Predictors of persistent low back pain • Poor pain coping behaviour • Presence of non-organic signs • High risk of baseline behaviour impairment • Low general health status • Psychiatric comordities • All predictors have low predictive values Chou et al. JAMA, April 7, 2010—Vol 303, No. 13 20 studies evaluating 10,842 patients

  5. The only population prospective study Tapcam et al. Pain 150:451, 2010

  6. Four clusters of low back pain

  7. Of all the causes of chronic low back pain, spondyloarthritis is the one most responsive to treatment

  8. New classification criteria for SpA 2009-2010 David Yu, 2010 dtyyu2003@163.com

  9. Why do we need to know new criteria? There are 4 major advances • Can be useful for diagnosis • Derived from 25 centers in 16 countries – with 5 centers in Asia • Consists of 2 different sets - one for axial SpA, the other from peripheral SpA • Uses MRI as a major new technique

  10. Most common SpA Undifferentiated SpA (USpA) Ankylosing spondlitis (AS)

  11. Why do we need to know new criteria? There are 3 major advances • Derived from 25 centers in 16 countries – with 5 centers in Asia • Consists of 2 different sets - one for axial SpA, the other from peripheral SpA • Uses MRI as a major new technique

  12. Two types of SpA presentation • Peripheral • Axial Oligo- arthritis Heel enthesitis Dactylitis

  13. ASAS Classification Criteria for Peripheral Spondyloarthritis (SpA) Arthritis or enthesitis or dactylitis plus ≥ 1 SpA feature • • • • • • ≥ 2 other SpA features • arthritis • enthesitis • dactylitis • inflammatory back pain (ever) • family history for SpA uveitis psoriasis Crohn‘s/colitis preceding infection HLA-B27 sacroiliitis on imaging OR Sensitivity: 75.0%, Specificity: 82.2%; n=266 Rudwaliet, EULAR 2009

  14. Are these patients suffering from peripheral SpA? Heel enthesitis Dactylitis Oligo-arthritis Rudwaleit M et al.

  15. ASAS Classification Criteria for Peripheral Spondyloarthritis (SpA) Heel swelling Sausage digit oligoarthritis Any one of the above plus • HLA-B27 Specificity: 82.2%; Sensitivity: 75.0%, n=266 SpA Rudwaleit M et al.

  16. What to do if B27 is negative Heel swelling Sausage digit oligoarthritis • • • arthritis heel swelling dactylitis If the patient has all 3 SpA Rudwaleit M et al.

  17. • • • arthritis heel swelling dactylitis If patient has only one of the 3 look for 2 of the following: IBD reactive arthritis Family history iritis psoriasis

  18. What to do if still not enough parameters? Heel swelling Sausage digit oligoarthritis • Imaging for sacroiliitis SpA Rudwaleit M et al.

  19. For patients with axial SpA

  20. Determine age of onset and duration mechancial low back pain < 3 months = not yet SpA < 3 months = not yet SpA mechancial low back pain SpA age of onset of pain <45 years old pain <45 years old SpA age of onset of

  21. First step in diagnosis of Axial SpA •HLA-B27 Add 1-2 SpA clinical features e.g • High CRP • Good response to NSAIDs Rudwaleit M et al. Ann Rheum Dis 2009;68:777-783 (with permission)

  22. Or any of the 2 below Family history diarrhea

  23. What to do if there are not enough parameters? Imaging for sacroiliitis Rudwaleit M et al. Ann Rheum Dis 2009;68:777-783

  24. Sequential steps in imaging • Do Plain X-ray of AP view of pelvis: grade right and left sacroiliac joints separately • If negative, and still suspicious of SpA, do MRI of the sacroiliac joints

  25. Definition of radiological sacroiliitis Sum of right and left joints > 4 or one side > 3

  26. Sequential steps in imaging • Do Plain X-ray of AP view of pelvis: grade right and left sacroiliac joints separately • If negative, and still suspicious of SpA, do MRI of the sacroiliac joints

  27. MRI diagnostic feature: (bone edema) STIR STIR edema edema STIR STIR

  28. Use of TNF blockers in Ankylosing spondylitis/axial spondylitis

  29. Questions we want to ask in ankylosing spondylitis • What are the indications • Are TNF blockers effective • How to predict degree of response to TNF blockers • How early in the disease should we start TNF blockers • Can we switch TNF blockers • Can we stop the TNF blockers after patients have entered remission • Can we stop the radiological progression with TNF blockers

  30. When should we start biologics in AS • High disease activity • Failed adequate NSAID therapy • Perhaps failed sulfasalazine/methotrexate

  31. Response of AS to TNF blockers • 75% respond very well to NSAIDs alone • For patients resistant to conventional therapies, 50% show 50% reduction in disease activities with TNF-blockers (infliximab, etanercept, adalimumab, golimumab)

  32. What is the best predictor of effectiveness of biologics • The earlier the biologics are started, the better the response • 80% responders in those with < 5 yr duration • 31% responders in those with >10 yr duration Rudwaleit et al: Ann Rheu Dis 67:1276, 2008 Giardina et al: Ann Rheum Dis Suppl II, 2008

  33. What are the other predictors of response to TNF blockers • Elevated CRP (LR 3.4) • Young age (<30 years) • Good functional status at baseline Haibel et al: Arth Rheum 58:1981, 1991 DANBIO: Ann Rheum Dis May 2010

  34. Lessons to be learnt • Treat early in the disease, even before there is radiological appearance of sacroiliitis • Use MRI to diagnose sacroiliitis if HLA- B27 is negative and plain X-ray does not show sacroiliitis – to diagnose AS Haibel et al: Arth Rheum 58:1981, 2008 Barkham et al: Arth Rheum 60:946, 2009

  35. Can we stop TNF blockers in AS • Not in most cases, disease will relapse, but will respond to retreatment Haibel et al: Curr Opin Rheumatol 22:388, 2010 Barkham et al: Ann Rheum Dis 68 (Suppl 3):72, 2009

  36. Can we switch TNF blockers in AS? RHAPSODY study • 326 AS patients previously treated with infliximab or etanercept or both consecutively – lack or loss of response or tolerance • These were given adalimumab for 12 weeks • 3% withdrew because of lack of response

  37. Can we switch TNF blockers in AS RHAPSODY study - continued • At 12 weeks, disease activity was improved in all participating patients • BASDAI50 response in 40.8% • For those who were not on TNF blockers before, the response was 63.0% Rudwaleit et al: Arth Res & Ther. 2010, 12:R117

  38. History of prior anti-TNF therapy Response rate      Prior ETN or IFX or both 115/305 (37.7)      No prior ETN/IFXa 518/873 (59.3) Prior TNF antagonist(s)      ETN only 25/81 (30.9)      IFX only 66/150 (44.0)      ETN and IFXa 24/74 (32.4) Reason for discontinuation of prior TNF antagonist      Loss of response 46/108 (42.6)      Intolerance 20/52 (38.5)      Lack of responsea 16/61 (26.2)

  39. Thank you UCLA, Los Angeles 余得恩 余得恩 David Yu, 2010 dtyyu2003@163.com