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That’s Just Swell

Spondyloarthritis and your joints

3d rendered illustration - painful shoulderSpondyloarthritis refers to a group of disorders where the joints of the spine and pelvis can become painful and swollen, also known as inflammation. Inflammation can also affect other joints, such as the hands and feet, and occasionally other organs, such as the skin, eyes, kidney, heart and gut.

Spondyloarthritis includes:

  • ankylosing spondylitis (most common)
  • psoriatic arthritis
  • reactive arthritis
  • arthritis related to inflammatory bowel disease
  • juvenile-onset spondyloarthritis
  • undifferentiated spondyloarthritis

Untreated, spondyloarthritis can lead to irreversible stiffness in the spine and destruction of the joints in the limbs and neck, which can severely impair mobility and reduce quality of life. There is currently no effective cure for the disease, but breakthroughs in therapeutics have markedly reduced long-term effects.

How common is spondyloarthritis?

Spondyloarthritis affects about 1.5% to 2% of the general population. The most common of the spondyloarthritides is ankylosing spondylitis, affecting an estimated  0.2% to 0.5% in Singapore. Psoriatic arthritis is estimated to affect 0.02% to 0.2% of the population.

Who is at risk of spondyloarthritis?

People with the “HLA-B27” gene are predisposed to spondyloarthritis, although the association varies amongst the different types of this disease, as well as amongst different ethnicities.

For example, the gene is present in more than 90% of patients with ankylosing spondylitis. Ankylosing spondylitis affects two to three times more males than females, and often appears before the age of 40 years. The risk of developing ankylosing spondylitis in a first degree relative of a patient (parent, sibling, or child) is about 8%.

Association of HLA-B27 is lower in patients with psoriatic arthritis and arthritis related to inflammatory bowel disease. The risk of developing reactive arthritis is higher in individuals with HLA-B27.

Should I test myself for HLA-B27?

About 4% to 8% of healthy individuals are positive for HLA-B27. As such, genetic testing is generally not recommended in patients without symptoms, as only 1% to 5% of HLA-B27 positive individuals in the general population will develop ankylosing spondylitis. Having the HLA-B27 gene does not mean that you will develop spondyloarthritis.

iStock_000047045738_LargeWhat are the symptoms of spondyloarthritis?

Ankylosing spondylitis is the most common form of spondyloarthritis, and symptoms usually begin in early adulthood, often before the age of 45 years:

  • Dull aches in the lower back and buttocks, with stiffness when waking up. This is often relieved with physical activity and medications such as non-steroidal anti-inflammatory agents (NSAIDs), and made worse with rest.
  • Pain where muscle tendons or ligaments attach to bone, often in the heels, around the pelvis and front of the chest
  • Pain and swelling of the shoulder, knee, ankle and hip joint
  • Neck stiffness and difficulty in turning the neck as the disease progresses
  • Inflammation of the eyes, heart and lungs
  • Fatigue

Arthritis can occur in up to 40% of patients with an existing skin condition called psoriasis. Nails are often disfigured, and more than half of those affected may experience neck pain. Patients can also develop swollen fingers and toes, also known as dactylitis.

Reactive arthritis frequently occurs after infections of the bowel or genital tract. The condition usually resolves on its own, but can last up to six months. Symptoms include inflammation of affected joints, red eyes, rashes over the hands and feet, diarrhea, mouth ulcers, fever, rashes over the tip of the penis and foul smelling discharge from the vagina or penis.

Patients with inflammatory bowel disease, such as Crohn’s disease and ulcerative colitis, can also have joint pain, which usually get better with improvement in bowel symptoms.

Juvenile-onset spondyloarthritis tends to affect boys younger than 16 years of age, usually involving joints in the lower limbs in an asymmetric fashion. Children tend to have swelling of their fingers and toes.

How is spondyloarthritis diagnosed?

Diagnosis is made based on symptoms and clinical signs elicited by your doctor. Blood tests, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are also ordered to look for evidence of inflammation, but results can be normal even when the disease is present. X-rays or magnetic resonance imaging (MRI) of the spine and sacroiliac joints also help in diagnosis. Identification of HLA-B27 is useful in patients with the correct clinical symptoms.

iStock_000031868870_LargeWhat are the treatment options available?

A team of healthcare professionals are needed to provide holistic care.

  • A rheumatologist is responsible for the care of the patient.
  • A physiotherapist is needed to give advice on exercises to maintain function and mobility.
  • An occupational therapist provides advice on joint protection, for example, through the prescription of splints or altering the way we perform tasks.
  • A podiatrist can assess your footcare needs and offer advice on special footwear.

Non-steroidal anti-inflammatory drugs (NSAIDs) can help reduce inflammation, pain and stiffness, and in some instances, reduce the rate of fusion of the spine. Disease modifying anti-rheumatic drugs (DMARDs), such as sulfasalazine, can also reduce pain and swelling of the joints.

Newer treatment options include the use of biological therapies. Biological therapies target specific inflammatory mediators, and can be given either by injection or through a drip into a vein.

Smoking is discouraged as it increases the amount of inflammation by up to five times compared to non-smokers.

What is the prognosis?

Generally, patients with spondyloarthritis will have flares from time to time, apart from reactive arthritis, which usually resolves by itself. With timely treatment, disability can be minimised in the long term.

However, those with severe disease can develop fusion of the spine or destruction of the joints in the limbs. This can greatly impair mobility, and affect their daily functioning.

Individuals with chronic disease, especially ankylosing spondylitis, are also at risk of developing osteoporosis and spinal fractures. Sufferers of psoriatic arthritis often also have heart disease, high blood pressure and obesity.

There is still much unknown about the cause of spondyloarthritis, and diagnosis remains a challenge. Despite current advances, up to 40% of patients do not respond well to therapy. Research is urgently needed to improve knowledge and understanding of the disease, and uncover new cures. A dedicated Rheumatology Research Fund (https://www.academicmedicine.edu.sg/MedicineACP/philanthropy-rheumatology-and-immunology) has been set up in Singapore General Hospital to help sustain long-term research, expedite research into disease flares, develop new therapies, and build and train a core team of committed research professionals.

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Dr Warren Fong is an Associate Consultant in the Department of Rheumatology and Immunology, Singapore General Hospital.
Posted by ezyhealth on Mar 31 2015. Filed under Health. You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.

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