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Spondyloarthropathies

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Spondyloarthropathies (SpA) are a group of common inflammatory rheumatic disorders characterised by axial and or peripheral arthritis, associated with enthesitis, dactylitis and potential extra-articular manifestations such as uveitis and skin rash. The diseases, which comprise the group, share a common genetic predisposition, the HLA-B27 gene; however, this association varies markedly among the various SpAs and among different ethnic groups. Environmental factors seem to be triggering the diseases in the genetically predisposed individuals. The radiographic hallmark of the group is sacroiliitis, which when present is of help in the diagnosis. Various sets of diagnostic and classification criteria were developed over the years including the European Spondyloarthropathy Study Group (ESSG) criteria which were until recently the most widely used. The new Assessment in SpondyloArthritis international Society (ASAS) international working group has recently proposed a new set of diagnostic criteria that would enable identification of SpA before structural changes develop in the spine. Magnetic resonance imaging (MRI) changes have now been included in the new classification criteria of early axial SpA and are now considered as a major tool in the diagnosis. Until recently, there were no real disease-modifying anti-rheumatic drugs which were able to halt the disease progression. Over the past decade, tumour necrosis factor (TNF)-alfa-blocking agents have been extensively investigated and became the mainstream of therapy providing the patients an effective treatment option.

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Signs and symptoms

AS is the most common and most typical form of SpA, with a prevalence of 0.2–1.2% in the Caucasian population [6], depending on regional genetic and environmental factors. This prevalence tends to be higher in populations with a higher prevalence of HLA-B27 positivity. Historically, AS was considered to affect men up to 10 times more commonly than women [7]; however, recent epidemiological studies demonstrated a lower male to female ratio, approximated at 2–3:1 [8]. The initial symptoms,

Laboratory findings and serological markers

There are no specific laboratory tests for the SPAs. The diagnosis is therefore made by combining clinical criteria with radiological findings. Inflammatory disease markers, such as CRP, serum amyloid A (SAA) and erythrocyte sedimentation rate (ESR), are generally elevated, though not in all patients, and are therefore less useful for monitoring disease activity of AS. However, CRP, SAA and interleukin-6 (IL-6) are currently still considered the best predictors of treatment response, and an

Pathogenesis and environmental aspects

The exact etiology and pathogenesis of the SpAs still remains unclear, though strong evidence supports the genetic background to play a major role in the susceptibility of this group of diseases, together with environmental factors, which seem to trigger the genetically predisposed, leading to the release of pro-inflammatory cytokines such as tumour necrosis factor (TNF)-alfa [28].

The first and most frequently documented genetic factor identified was the tissue antigen HLA-B27. This gene

Worldwide incidence and prevalence

Many studies have attempted to assess the estimates of the incidence and prevalence of AS and SpAs in various populations using different methods. Using a 50-year period hospital attendance in Rochester, US, the incidence of AS was found to be approximately 1 per 10,000 males per year and one-third of that in females [43]. Similar findings were found in a Norwegian as well as in a Finish population over a 10-year period [44]. Thus, these rather almost identical findings indicate the constancy

Diagnostic criteria

The various sets of validated diagnostic criteria which have been proposed over the years for the diagnosis of the SpAs have been recently summarised in a special supplement of the Annals of the Rheumatic Diseases dedicated to this issue [52]. The new ASAS international working group has proposed a new set of diagnostic criteria that would enable identification of SpA before structural changes develop in the spine [26], [27]. These criteria which are for both axial SpA as well as peripheral SpA

Prognosis

SpAs are characterised by mild to moderate flares of active inflammation alternating with periods of little or no inflammation. Proper treatment will result in most patients with minimal or no disability, and in productive life despite back stiffness. A small minority of patients with chronic progressive incapacitating disease will develop disability due to spinal fusion, often with thoracic kyphosis or erosive disease involving peripheral joints, especially of the hips and shoulders. Apart

Prevention

Since genetic factors appear to play a role in AS and other SpAs, it is not possible to prevent the disease. Being aware, however, of any personal risk factors for the disease may help in early detection and treatment. People who have a family member with AS and bear the HLA-B27 gene, and are younger than 40, have a chance of about 20% to develop the disease. If they are however older than 40, their chances of getting AS are low. Failure to identify SpAs and subsequently treat it effectively

Therapy and prevention of the spondyloarthritides

NSAIDs taken in full anti-inflammatory doses, in combination with physical therapy, were and still are the basic essential therapeutic modality for patients with SpAs which are aimed only at symptomatic control of the disease. Management of patients with AS should be based on the symptoms and signs, disease activity and severity, and functional status. Sulfasalazine (SZA) is often used in the treatment of AS and other SpAs, mainly for the control of peripheral joint involvement, for which it

Summary

SpAs are a group of common related inflammatory rheumatic disorders with overlapping features as well as genetic and familial associations. Axial and peripheral arthritis, enthesitis, dactylitis and potential extra-articular manifestations such as uveitis and skin rash are the hallmarks of this group of diseases. Environmental factors seem to be triggering the diseases in the genetically predisposed individuals. The radiographic hallmark of the group is sacroiliitis. The new ASAS international

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