Pharmacists Can Help Defeat the Challenge of Early Diagnosis in Ankylosing Spondylitis
At some point in life, virtually every adult ends up with an aching back. It’s so common that most people are conditioned to self-treat and move on—but that approach can lead to dire outcomes if the ache is caused by ankylosing spondylitis. It is a type of arthritis takes people by surprise because its characteristics are so uncommon and its symptoms are so insidious.
Writing off spondylitis as an occasional backache is a problem because without treatment, the spine will fuse. Pharmacists who are familiar with the characteristics of spondylitis can quickly assess their patients with back pain, alert those at risk for spondylitis, and give them the opportunity to get help before it’s too late.
Why Pharmacists Should Be Alert for Patients at Risk for Ankylosing Spondylitis
One of the biggest concerns about ankylosing spondylitis (AS) is that it’s either not diagnosed because patients don’t consult a doctor or it’s misdiagnosed, delaying diagnosis by 8.5 to 11.4 years.1 At the same time, it’s easy to understand why AS is so difficult to diagnosis. For one thing, symptoms may be mild and, like with backaches from normal activities, the pain can come-and-go. Arthritis isn’t likely to be the first differential diagnosis considered because AS doesn’t fit the expected profile of arthritis:
- Most cases occur by the age of 40 and about 80 percent develop AS before the age of 30.2
- Ten to 20 percent of all patients experience symptoms before the age of 16.
- AS affects more men than women by 2-3:1, compared to osteoarthritis and rheumatoid arthritis, which occur in significantly more women than men.
- Primarily affects the sacroiliac joints and axial skeleton.
AS is classified as a spondyloarthropathy and is often found with other diseases from that group, such as ulcerative colitis, Crohn disease, reactive arthritis and psoriatic arthritis. This further confounds the diagnosis, as patients may have symptoms that divert attention away from back pain. Like other forms of arthritis, AS is chronic, inflammatory and often affects multiple systems.
The prognosis is better than for rheumatoid arthritis, but there’s still bad news. More than one-third of AS patients find they must switch to less physically demanding jobs. Some develop chronic progressive disease, leading to spinal fusion and disability. A study published in the Annals of Internal Medicine in September 2015 reported that people with AS have a 50 percent increased risk for vascular mortality.3
Most functional loss caused by AS occurs during the first 10 years—a time when proper treatment may have prevented or limited impairment. Considering the typical delay in diagnosis, it’s vital for pharmacists to be proactive and reach out to patients suffering from lower back pain.
Key Symptoms of Ankylosing Spondylitis
The slow progression of AS sneaks up on patients until their once-tolerable symptoms become painful enough to motivate a trip to the doctor. It typically takes at least three months for symptoms to finally grab the patient’s attention, but it can also take years. As a general guideline, pain appears along the spine and in the pelvis, sacroiliac joints, heels, and chest. Here’s a rundown of symptoms your patients might report:
- Patients may have no symptoms or mild pain and stiffness at the start.
- Early-stage symptoms are usually unilateral.
- Dull inflammatory low-back pain and stiffness are common.
- Buttock pain occurs in 80 percent of patients.
- Symptoms are worse in the morning, with stiffness lasting at least 30 minutes.
- Intermittent symptoms are common as patients usually experience flare-ups, but when the disease is active, 70 percent of patients have daily pain.
- Back pain improves with exercise but not with rest.
- Nearly 65 percent of patients have moderately severe fatigue.
- Peripheral musculoskeletal symptoms due to inflammation are found in 30 to 50 percent of cases.
As the disease progresses, 20 percent report psychological disorders such as depression. Uveitis is also a common comorbidity—about one-third of patients can expect to develop uveitis at least once.
Pharmacologic and Lifestyle Treatments
The American College of Rheumatology, together with the Spondylitis Association of America and the Spondyloarthritis Research and Treatment Network, released the first treatment guidelines for AS in September 2015. In a nutshell, the core recommendations include NSAIDS, tumor necrosis factor inhibitors (TNFi) and physical therapy:4
- NSAIDS for adults with active AS, but no preference for a particular type of NSAID. Indomethacin was considered the first-line choice, but the available data shows it’s not more effective than other NSAIDS.
- TNFis for adults when activity persists despite NSAID treatment. No specific TNFi is preferred except infliximab or adalimumab are preferred over etanercept for adults with comorbid inflammatory bowel disease.
- Strongly recommend against using systemic glucocorticoids in adults with active AS.
- Conditionally recommend against treatment with slow-acting antirheumatic drugs.
- Physical therapy—recommend referral to a physical therapist or rehabilitation specialist
- Total hip arthroplasty for those with AS and advanced hip arthritis
If your patients have a fused spine and experience any movement of the spine, there’s a high probability they have a spinal fracture that may require surgical stabilization. Patients with fusion of the cervical or upper thoracic spine may benefit from extension osteotomy, but be aware that it’s an extremely hazardous procedure with high risk for morbidity.
Critical Role of Pharmacist Outreach
In an interview with Medscape Medical News, Joel D. Taurog, MD, the William M. and Gay Burnett Professorship for Arthritis Research at the University of Texas Southwestern Medical School, emphasized that the unmet need for early and accurate diagnosis is greater than the unmet need for appropriate treatment of diagnosed cases.5 Dr. Taurog said, “The providers who first encounter patients with axial symptoms are rarely rheumatologists and educating these providers on the nature of [SpA] and the need for rheumatologic referral is a major challenge for our subspecialty.” Pharmacists can help these patients by talking with them about ankylosing spondylitis and referral to a rheumatologist.
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- “Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy,” January 2016, http://emedicine.medscape.com/article/332945-overview ↩
- “Ankylosing Spondylitis,” October 2012, http://www.hopkinsarthritis.org/arthritis-info/ankylosing-spondylitis/ ↩
- “Patients With Ankylosing Spondylitis Have Increased Cardiovascular and Cerebrovascular Mortality: A Population-Based Study,” September 2015, http://annals.org/article.aspx?articleid=2424871 ↩
- “American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis,” September 2015, http://onlinelibrary.wiley.com/doi/10.1002/art.39298/abstract ↩
- “First Guideline on Ankylosing Spondylitis Issued by ACR,” October 2015, http://www.medscape.com/viewarticle/852225 ↩