Management and evaluation of extra-articular manifestations in spondyloarthritis

Abstract

Spondyloarthritis (SpA) is a chronic inflammatory disease with either predominantly axial symptoms of the spine and sacroiliac joints (axial SpA, including ankylosing spondylitis) or predominantly arthritis (peripheral SpA). Next to these spinal and articular symptoms, many patients with SpA also have extra-articular manifestations (EAMs). EAMs associated with SpA include anterior uveitis (25-30%), psoriasis (10-25%) or inflammatory bowel disease (IBD) (5-10%) and cardiovascular manifestations. Peripheral arthritis occurs in approximately 30% of patients, especially in large joints, and shows an asymmetrical, oligoarticular pattern. Other common joint complaints are due to enthesitis, which manifest as extra-articular bony tenderness in areas such as the Achilles tendon. Acute anterior uveitis presents with acute pain, loss of vision and redness in one eye that usually subsides spontaneously after several weeks. Rapid treatment by an ophthalmologist is required to prevent synechiae formation which could ultimately result in glaucoma and blindness. Although less common, organ involvement in SpA can also be located in the heart, lungs or kidneys. The risk of cardiovascular events is increased in SpA. Cardiac manifestations can involve the aortic valve (1-10%) or the atrioventricular node and the risk of atherosclerotic events is increased in this group. Treatment of SpA includes physical exercise and nonsteroidal anti-inflammatory drugs (NSAIDs), and in case of peripheral arthritis, sulphasalazine can be added. When there is insufficient response to NSAIDs, tumor necrosis factor blockers, especially infliximab, etanercept, adalimumab and golimumab, are very effective in treating axial manifestations, arthritis, enthesitis and psoriasis. Anterior uveitis in SpA can be treated adequately by the ophthalmologist and in the case of refractory uveitis, treatment with adalimumab and infliximab seems to be more effective compared with etanercept. When IBD occurs with SpA, the use of NSAIDs should be minimized, except for celecoxib, and infliximab or adalimumab are preferred to etanercept. The incidence of atherosclerotic events or SpA-specific cardiac manifestations may be decreased by cardiovascular risk management or effective antirheumatic treatment. Overall it is important to realize that extra-articular manifestations frequently occur in patients with SpA and should be taken into account in the choice of treatment.

Juvenile spondyloarthritis

“…Approximately two-thirds of adults with SpA have inflammatory bowel symptoms comparable to that seen in patients with IBD (29); similar prevalence rates have been reported in children (30). The exact prevalence of psoriasis in JSpA is unclear but psoriasis has been reported in 10–25% of SpA (31). Cardiac complications of SpA are well documented in adults but scarce in JSpA.…”

Observed Incidence of Uveitis Following Certolizumab Pegol Treatment in Patients With Axial Spondyloarthritis

“…Reports from patients with established AS suggest that ∼40% of patients will experience 1 or more uveitis flares during the course of their disease , and observational data sources (such as cohort studies and patient registries) have reported that 10–30% of axial SpA patients classified using the Assessment of SpondyloArthritis international Society (ASAS) criteria have a history of uveitis . Moreover, an attack of acute anterior uveitis (AU) can be the first presenting symptom that leads to a diagnosis of axial SpA .…”

Is the use of AGILE patency capsule prior to videocapsule endoscopy useful in all patients with spondyloarthritis?

“…There is a percentage of 5-10 % of patients with SpA that will develop inflammatory bowel disease and a much higher percentage, close to 60% of patients that have asymptomatic bowel inflammatory lesions [8]. But despite this evidence, in these patients an endoscopic assessment of the entirety of the small bowel is not performed in a systematic manner.…”