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Spondyloarthritis Psoriatic Arthritis Psoriatic arthritis is an inflammatory joint disease associated with psoriasis. Psoriasis affects approximately 3% of the U.S. population, and psoriatic arthritis may develop in up to 30% of patients with psoriasis. Hyperuricemia and gout are comor bidities associated with psoriasis and psoriatic arthritis. An estimated 15% of patients with psoriasis who are monitored by dermatologists have unrecognized psoriatic arthritis. On the other hand, some patients considered to have psoriatic arthritis because of concurrent psoriasis and joint pain actually have an unrelated joint condition, most commonly osteoarthritis. In most cases, psoriatic arthritis develops years after psoriasis, but 15% of patients may develop psoriatic arthritis concurrently with or even before psoriasis. The male to-female ratio for psoriatic arthritis is 1:1 (other forms of spondyloarthritis generally have a higher FIGU RE I 7. Marked thickening of the distal right Achilles tendon and Achilles insertion on the calcaneus (right) as the result of chronic Achilles tendinitis in a prevalence in men). Risk factors include obesity, metabolic patient with psoriatic arthritis (left image shows normal contralateral on Achilles syndrome, severe psoriasis, psoriasis involving the scalp or i nsertion). genitals, or inverse psoriasis. Psoriatic nail changes are pre- sent in more than 80% of patients with psoriatic arthritis. Fibrosis affecting the upper lobes of the lung, visualized The genetics of psoriatic arthritis are complex. HLA-C06 is by high-resolution CT, is reported in 7% of patients with early associated with psoriasis but not psoriatic arthritis. HLA- ankylosing spondylitis and 2l% of patients after 10 years of BO8, -B27, -B38, and -B39 are seen in psoriatic arthritis, and disease. Involvement of the thoracic spine, costochondral the particular HLA type can influence clinical expression. In junctions, and sternomanubrial joint can affect chest expan- part because of HLA expression, psoriatic arthritis is rare in sion, contributing to restrictive lung disease. Asians and Africans. Renal amyloidosis is a rare manifestation of chronic Five clinical subtypes ofpsoriatic arthritis are described: inflammation from ankylosing spondylitis that occurs in 1. Asymmetric oligoarthritis involving four or fewer, typically patients with long-standing, poorly controlled disease. AA large, joints. Occasionally, a single joint may be involved. amyloid deposition can lead to proteinuria and eventually kidney failure and is associated with increased mortality. In 2. Polyarticular arthritis affecting multiple joints of the patients with poorly controlled ankylosing spondylitis, AA hands, which may be symmetrical and resemble rheuma amyloidosis is the most common cause of kidney disease. IgA toid arthritis. nephropathy can also occur in anlcylosing spondylitis, pre- 3. Distal interphalangeal joint (DlP)-predominant variety, senting as hematuria and proteinuria. which may occur with the preceding subtl,pes or in isolation Cardiac involvement in ankylosing spondylitis includes aortitis ofthe subaortic valve region (an area ofhigh fibrocar- tilage content), leading to aortic dilatation and aortic valve regwgitation. Atrioventricular block occurs more commonly in patients with ankylosing spondylitis and those who are HLA-827 positive without rheumatologic disease than among the general population. Myocardial infarction occurs in patients with antr<ylosing spondylitis at a rate two to three times that in the general population; this increased rate is thought to be due to chronic inflammation hastening the development of atherosclerosis. Vertebral fractures can occur in patients with ankylosing spondylitis, often after only minor or minimal trauma. Fractures can occur through the vertebral body or through a disk space that has become fixed because of slmdesmophyte formation; either can lead to nerve injury or myelopathy Another rare nzu- rologic manifestation is cauda equine qmdrome, manifested by F IG UR E 1 8. Radiograph showing hip involvement in ankylosing spondylitis. saddle anesthesia and bowel and bladder incontinence. MRI of Note the fused sacroiliac joints bi lateral ly. Diffuse joi nt-space narrowi ng is present the lumbar spine shows arachnoid diverticula in these patients. in both hip joints, especially in the left hip.

Psoriatic Arthritis Psoriatic arthritis is an inflammatory joint disease associated with psoriasis. Psoriasis affects approximately 3% of the U.S. population, and psoriatic arthritis may develop in up to 30% of patients with psoriasis. Hyperuricemia and gout are comor bidities associated with psoriasis and psoriatic arthritis. An estimated 15% of patients with psoriasis who are monitored by dermatologists have unrecognized psoriatic arthritis. On the other hand, some patients considered to have psoriatic arthritis because of concurrent psoriasis and joint pain actually have an unrelated joint condition, most commonly osteoarthritis. In most cases, psoriatic arthritis develops years after psoriasis, but 15% of patients may develop psoriatic arthritis concurrently with or even before psoriasis. The male to-female ratio for psoriatic arthritis is 1:1 (other forms of spondyloarthritis generally have a higher FIGU RE I 7. Marked thickening of the distal right Achilles tendon and Achilles insertion on the calcaneus (right) as the result of chronic Achilles tendinitis in a prevalence in men). Risk factors include obesity, metabolic patient with psoriatic arthritis (left image shows normal contralateral on Achilles syndrome, severe psoriasis, psoriasis involving the scalp or i nsertion). genitals, or inverse psoriasis. Psoriatic nail changes are pre- sent in more than 80% of patients with psoriatic arthritis. Fibrosis affecting the upper lobes of the lung, visualized The genetics of psoriatic arthritis are complex. HLA-C06 is by high-resolution CT, is reported in 7% of patients with early associated with psoriasis but not psoriatic arthritis. HLA- ankylosing spondylitis and 2l% of patients after 10 years of BO8, -B27, -B38, and -B39 are seen in psoriatic arthritis, and disease. Involvement of the thoracic spine, costochondral the particular HLA type can influence clinical expression. In junctions, and sternomanubrial joint can affect chest expan- part because of HLA expression, psoriatic arthritis is rare in sion, contributing to restrictive lung disease. Asians and Africans. Renal amyloidosis is a rare manifestation of chronic Five clinical subtypes ofpsoriatic arthritis are described: inflammation from ankylosing spondylitis that occurs in 1. Asymmetric oligoarthritis involving four or fewer, typically patients with long-standing, poorly controlled disease. AA large, joints. Occasionally, a single joint may be involved. amyloid deposition can lead to proteinuria and eventually kidney failure and is associated with increased mortality. In 2. Polyarticular arthritis affecting multiple joints of the patients with poorly controlled ankylosing spondylitis, AA hands, which may be symmetrical and resemble rheuma amyloidosis is the most common cause of kidney disease. IgA toid arthritis. nephropathy can also occur in anlcylosing spondylitis, pre- 3. Distal interphalangeal joint (DlP)-predominant variety, senting as hematuria and proteinuria. which may occur with the preceding subtl,pes or in isolation Cardiac involvement in ankylosing spondylitis includes aortitis ofthe subaortic valve region (an area ofhigh fibrocar- tilage content), leading to aortic dilatation and aortic valve regwgitation. Atrioventricular block occurs more commonly in patients with ankylosing spondylitis and those who are HLA-827 positive without rheumatologic disease than among the general population. Myocardial infarction occurs in patients with antr<ylosing spondylitis at a rate two to three times that in the general population; this increased rate is thought to be due to chronic inflammation hastening the development of atherosclerosis. Vertebral fractures can occur in patients with ankylosing spondylitis, often after only minor or minimal trauma. Fractures can occur through the vertebral body or through a disk space that has become fixed because of slmdesmophyte formation; either can lead to nerve injury or myelopathy Another rare nzu- rologic manifestation is cauda equine qmdrome, manifested by F IG UR E 1 8. Radiograph showing hip involvement in ankylosing spondylitis. saddle anesthesia and bowel and bladder incontinence. MRI of Note the fused sacroiliac joints bi lateral ly. Diffuse joi nt-space narrowi ng is present the lumbar spine shows arachnoid diverticula in these patients. in both hip joints, especially in the left hip. 36

Spondyloarthritis Enteropathic Arthritis Ankylosing spondyloarthritis, isolated sacroiliitis, and periph- eral arthritis occur in patients with Crohn disease, ulcerative colitis, and unspecified inflammatory bowel disease (IBD). Spondyloarthritis is the most common extra-articular mani- festation of IBD. The prevalence of ankylosing spondylitis is 47o in Crohn disease and 2% in ulcerative colitis; the prwalence of isolated sacroiliitis is 137" and 7olo, respectively. Of interest, HLA-827 is found in 257o to 75% ofpatients with enteropathy-associated ankylosing spondylitis but in only 7"/" to lSTo of those with isolated sacroiliitis, suggesting a different pathophysiologr. Isolated sacroiliitis is unilateral in 60% of cases and can be associated with psoriasis, erythema nodosum, and peripheral arthritis in patients with IBD. Dactylitis and enthesitis can also occur with enteropathic spondyloarthritis. There are two types of peripheral arthritis in IBD. Type I is pauciarticular (fewer than five joints) and asymmetric; usually involves medium to large joints, especially in the lower extremities; is nonerosive; and parallels the activity of the bowel disease. Type II is polyarticular (five or more joints); is qmmetric; involves a wide range of joints, some- t I G U n E t 9 . Distal interphalangeal joint swelling (best seen in the second and times including the upper extremities; is nonerosive; and is third digits) and nail pitting (best seen in the fourth digit nail) in a patient with psoriatic arthritis. persistent and independent of bowel disease activity. The prevalence of peripheral arthritis is highest in younger patients (up to ZS%) and much lower in patients older than (Figure 19). Although inflammation in a DIP joint in a age 5o years (2%). patient with psoriasis strongly suggests psoriatic arthritis, The risk for IBD in patients with established spondy- DIP involvement is also common in osteoarthritis, is occa- loarthritis is as high as 147o and is highest in patients with sionally seen in gout, and also occurs in a rare condition ankylosing spondylitis. As noted previously, 60% ofpatients called multicentric reticulohistiocytosis. with ankylosing spondylitis have evidence of asymptomatic 4. Arthritis mutilans, a more aggressive form of psoriatic bowel inflammation, and most patients with ankylosing arthdtis irvolving the hands. Telescoping of the digits from spondylitis who develop IBD are in this group. Patients zubstantial joint destruction may ocu:r. Arthritis mutilans is with ankylosing spondylitis should be asked about bowel probably a progressive form ofthe preceding thrce subtypes. symptoms on follow-up visits. Elevated serum and fecal 5. Axial spine involvement with sacroiliitis and spine involve- calprotectin levels can identi$r patients with ankylosing spondylitis who have greater disease activity and those with ment. This may occur in isolation or in conjunction with other subtypes. It occurs in up to 5Oo/. of patients with psoriatic arthritis, more commonly among patients with the HIA-827 gene. Axial psoriatic arthritis involvement may be distinguished radiographicallyby asymmetry skip lesions, and bulkier syndesmophytes. Enthesitis is common in psoriatic arthritis and indicates more severe disease. Dactylitis of the fingers or toes develops in 4O% to 50% of patients with psoriatic arthritis (Flgur€ 2O); enthesitis ofthe plantar fascia or Achilles tendon occurs in up to 5O%. Eye involvement also develops in psoriatic arthritis. Conjunctivitis is more common than uveitis or iritis. Uveitis occurs in up to 8% of patients with psoriatic arthritis. Like ankylosing spondylitis, psoriatic arthritis is associ- ated with an increased risk for cardiovascular disease, includ- ing myocardial infarction, valvular disease, and conduction FTGURE 20. Dactylitisof thesecondtoesbilaterallyinapatientwithpsoriatic abnormalities. arthritis.

Enteropathic Arthritis Ankylosing spondyloarthritis, isolated sacroiliitis, and periph- eral arthritis occur in patients with Crohn disease, ulcerative colitis, and unspecified inflammatory bowel disease (IBD). Spondyloarthritis is the most common extra-articular mani- festation of IBD. The prevalence of ankylosing spondylitis is 47o in Crohn disease and 2% in ulcerative colitis; the prwalence of isolated sacroiliitis is 137" and 7olo, respectively. Of interest, HLA-827 is found in 257o to 75% ofpatients with enteropathy-associated ankylosing spondylitis but in only 7"/" to lSTo of those with isolated sacroiliitis, suggesting a different pathophysiologr. Isolated sacroiliitis is unilateral in 60% of cases and can be associated with psoriasis, erythema nodosum, and peripheral arthritis in patients with IBD. Dactylitis and enthesitis can also occur with enteropathic spondyloarthritis. There are two types of peripheral arthritis in IBD. Type I is pauciarticular (fewer than five joints) and asymmetric; usually involves medium to large joints, especially in the lower extremities; is nonerosive; and parallels the activity of the bowel disease. Type II is polyarticular (five or more joints); is qmmetric; involves a wide range of joints, some- t I G U n E t 9 . Distal interphalangeal joint swelling (best seen in the second and times including the upper extremities; is nonerosive; and is third digits) and nail pitting (best seen in the fourth digit nail) in a patient with psoriatic arthritis. persistent and independent of bowel disease activity. The prevalence of peripheral arthritis is highest in younger patients (up to ZS%) and much lower in patients older than (Figure 19). Although inflammation in a DIP joint in a age 5o years (2%). patient with psoriasis strongly suggests psoriatic arthritis, The risk for IBD in patients with established spondy- DIP involvement is also common in osteoarthritis, is occa- loarthritis is as high as 147o and is highest in patients with sionally seen in gout, and also occurs in a rare condition ankylosing spondylitis. As noted previously, 60% ofpatients called multicentric reticulohistiocytosis. with ankylosing spondylitis have evidence of asymptomatic 4. Arthritis mutilans, a more aggressive form of psoriatic bowel inflammation, and most patients with ankylosing arthdtis irvolving the hands. Telescoping of the digits from spondylitis who develop IBD are in this group. Patients zubstantial joint destruction may ocu:r. Arthritis mutilans is with ankylosing spondylitis should be asked about bowel probably a progressive form ofthe preceding thrce subtypes. symptoms on follow-up visits. Elevated serum and fecal 5. Axial spine involvement with sacroiliitis and spine involve- calprotectin levels can identi$r patients with ankylosing spondylitis who have greater disease activity and those with ment. This may occur in isolation or in conjunction with other subtypes. It occurs in up to 5Oo/. of patients with psoriatic arthritis, more commonly among patients with the HIA-827 gene. Axial psoriatic arthritis involvement may be distinguished radiographicallyby asymmetry skip lesions, and bulkier syndesmophytes. Enthesitis is common in psoriatic arthritis and indicates more severe disease. Dactylitis of the fingers or toes develops in 4O% to 50% of patients with psoriatic arthritis (Flgur€ 2O); enthesitis ofthe plantar fascia or Achilles tendon occurs in up to 5O%. Eye involvement also develops in psoriatic arthritis. Conjunctivitis is more common than uveitis or iritis. Uveitis occurs in up to 8% of patients with psoriatic arthritis. Like ankylosing spondylitis, psoriatic arthritis is associ- ated with an increased risk for cardiovascular disease, includ- ing myocardial infarction, valvular disease, and conduction FTGURE 20. Dactylitisof thesecondtoesbilaterallyinapatientwithpsoriatic abnormalities. arthritis. 37

Spondyloarthritis Peripheral joint changes in spondyloarthritis include ero- sions and new bone formation. In psoriatic arthritis in par- ticular, radiographic findings classically take the form of erosions of the distal head of the proximal joint and juxta- articular new bone formation at the proximal head of the distaljoint, leading to a 'pencil-in-cup" appearance across the joint (Figure 27).

Peripheral joint changes in spondyloarthritis include ero- sions and new bone formation. In psoriatic arthritis in par- ticular, radiographic findings classically take the form of erosions of the distal head of the proximal joint and juxta- articular new bone formation at the proximal head of the distaljoint, leading to a 'pencil-in-cup" appearance across the joint (Figure 27). . Except for incidental overlap with other conditions, HVC patients with spondyloarthritis are negative for rheu- matoid factor, anti-cyclic citrullinated peptide, and antinuclear antibodies; HI,A-B27 antigen tesung can help determine risk for spondyloarthritis in uncertain situations. r Erythrocyte sedimentation rate and C-reactive protein can help confirm an inflammatory process and can be monitored during therapy; however, these values are not always elevated, particularly in ankylosing spondylitis. o Radiography of the sacroiliac joints is an initial diagnos- tic test for patients suspected ofhaving ankylosing spondylitis; radiographic widence of sacroiliitis includes pseudo-widening of the joints, erosions, sclerosis, and ankylosis. e MRI of the sacroiliac joints is more sensitive than CT HVC

. Except for incidental overlap with other conditions, HVC patients with spondyloarthritis are negative for rheu- matoid factor, anti-cyclic citrullinated peptide, and antinuclear antibodies; HI,A-B27 antigen tesung can help determine risk for spondyloarthritis in uncertain situations. r Erythrocyte sedimentation rate and C-reactive protein can help confirm an inflammatory process and can be monitored during therapy; however, these values are not always elevated, particularly in ankylosing spondylitis. o Radiography of the sacroiliac joints is an initial diagnos- tic test for patients suspected ofhaving ankylosing spondylitis; radiographic widence of sacroiliitis includes pseudo-widening of the joints, erosions, sclerosis, and ankylosis. e MRI of the sacroiliac joints is more sensitive than CT HVC F I G UR E 2 6 . More advanced disease of the lumbar spine in late ankylosing and can identiff sacroiliac inflammation even in the spondylitis. Note the syndesmophyte formation or bony connections between absence ofradiographic changes; however, 25"/, of vertebrae across the disc space ("bamboo" appearance). healthy individuals can have similar MRI changes. (Continued)

F I G UR E 2 6 . More advanced disease of the lumbar spine in late ankylosing and can identiff sacroiliac inflammation even in the spondylitis. Note the syndesmophyte formation or bony connections between absence ofradiographic changes; however, 25"/, of vertebrae across the disc space ("bamboo" appearance). healthy individuals can have similar MRI changes. (Continued) syndesmophytes (delicate bony bridging between vertebrae that can result in a "bamboo" appearance of the spine in advanced ankylosing spondylitis [Figure 26]); sclerosis at the facet joints; and, in more advanced cases, ossification of the anterior longitudinal ligament. Patients with psoriatic arthritis or reactive arthritis with spondylitis can also have syndesmo- phytes; these tend to be bulkier and more asymmetrically placed than syndesmophytes in ankylosing spondylitis. Whiskering, the result of new bone formation at the insertion of the hamstrings into the pelvis, is also seen on radiography. Bony proliferation can occur in other entheses, such as the Achilles tendon or plantar fascia insertion into the heel. Low dose CT and MRI of the sacroiliac joints can be done if necessary Low dose CT is more speciflc and is usefirl to clari$r ambigrous changes seen on plain radiographs, whereas MRI is more sensitive and can ident$ sacroiliac inflammation even in the absence ofradiographic changes. However, 25% ofhealthy indMduals can have MRI changes that meet Assessment of SpondyloArthritis international Society criteria for sacroiliitis, and up to 41% of persons who regularly participate in impact- loading athletics may have similar MRI changes. The extent of J involvement and presence of erosions on MRI increase the t I G U R E 2 7 . Radiograph showing "pencil-in-cup' deformity of the fifth speciflcity of the result. The presence of MRI changes also aids metatarsal joint and ankylosis of the fou rth metatarsal joint in a patient with in the diagnosis of nonradiographic axial spondyloarthritis. psoriatic arthritis.

syndesmophytes (delicate bony bridging between vertebrae that can result in a "bamboo" appearance of the spine in advanced ankylosing spondylitis [Figure 26]); sclerosis at the facet joints; and, in more advanced cases, ossification of the anterior longitudinal ligament. Patients with psoriatic arthritis or reactive arthritis with spondylitis can also have syndesmo- phytes; these tend to be bulkier and more asymmetrically placed than syndesmophytes in ankylosing spondylitis. Whiskering, the result of new bone formation at the insertion of the hamstrings into the pelvis, is also seen on radiography. Bony proliferation can occur in other entheses, such as the Achilles tendon or plantar fascia insertion into the heel. Low dose CT and MRI of the sacroiliac joints can be done if necessary Low dose CT is more speciflc and is usefirl to clari$r ambigrous changes seen on plain radiographs, whereas MRI is more sensitive and can ident$ sacroiliac inflammation even in the absence ofradiographic changes. However, 25% ofhealthy indMduals can have MRI changes that meet Assessment of SpondyloArthritis international Society criteria for sacroiliitis, and up to 41% of persons who regularly participate in impact- loading athletics may have similar MRI changes. The extent of J involvement and presence of erosions on MRI increase the t I G U R E 2 7 . Radiograph showing "pencil-in-cup' deformity of the fifth speciflcity of the result. The presence of MRI changes also aids metatarsal joint and ankylosis of the fou rth metatarsal joint in a patient with in the diagnosis of nonradiographic axial spondyloarthritis. psoriatic arthritis. 40

Spondyloa rth ritis f,EY P0lI|TS {ontinued) long-term doses of anti inflammatory agents (e.g., naproxen, . In psoriatic arthritis radiographic findings take the form 500 mg twice daily; piroxicam, 20 mg daily) are required to modi$r new bone formation and decrease inflammation. A dose of erosions of the distal head of the proximal joint and juxta-articular new bone formation at the proximal of a longer acting NSAID at dinnertime can make the patient comfortable throughout the night and into the moming. head of the distal joint, leading to a "pencil in cup" According to the 2019 ACR guidelines, patients in whom appearance across the joint. NSAIDs fail can be treated with a tumor necrosis factor (TNF) inhibitor. Numerous randomized controlled trials have shown improvements in clinical, radiographic, and MRI outcomes in Management patients with active ankylosing spondylitis taking TNF inhibi General Considerations tors. Routine serial spine radiography for monitoring is not Management of spondyloarthritis focuses on treatment of inflam recommended. mation and autoimmunit5r to address pain and prwent structural When a TNF inhibitor fails, patients should receive an damage. If damage has occurred, mechanical pain must be interleukin-l7 inhibitor in lieu of a second TNF agent. For addressed as well. Patient education, exercises to maintain range patients with significant peripheral arthritis, sulfasalazine is of motion and control weight, and modilication of diet and life- recommended over methotrexate and can be added to the style habits to prevent cardiovascular disease are vital. biologic agent if needed. However, these agents have little or no ellect on axial disease. Ankylosing Spondylitis Uveitis is generally treated with topical glucocorticoids. Figure 28 details recommendations for initial treatment of For severe or frequent recurrences, the TNF inhibitors adali- active ankylosing spondylitis. NSAIDs are recommended as mumab or infliximab can be considered. Etanercept, an anti initial medication for most patients with ankylosing spondylitis TNF receptor fusion protein, is effective for the spine but because they relieve pain and improve stiffness. Given the probably not eye disease. unique potential for disease modiflzing effects (oniy in ankylos- Physical therapy to maintain general range of motion is ing spondylitis), the American College of Rheumatolo$/ (ACR) essential. Patients with damage to hip or shoulder joints may conditionally recommends continuous NSAID use (rather than require total joint arthroplasty, which may dramatically on demand use) for patients with active disease. Higher and improve function and quality of life.

f,EY P0lI|TS {ontinued) long-term doses of anti inflammatory agents (e.g., naproxen, . In psoriatic arthritis radiographic findings take the form 500 mg twice daily; piroxicam, 20 mg daily) are required to modi$r new bone formation and decrease inflammation. A dose of erosions of the distal head of the proximal joint and juxta-articular new bone formation at the proximal of a longer acting NSAID at dinnertime can make the patient comfortable throughout the night and into the moming. head of the distal joint, leading to a "pencil in cup" According to the 2019 ACR guidelines, patients in whom appearance across the joint. NSAIDs fail can be treated with a tumor necrosis factor (TNF) inhibitor. Numerous randomized controlled trials have shown improvements in clinical, radiographic, and MRI outcomes in Management patients with active ankylosing spondylitis taking TNF inhibi General Considerations tors. Routine serial spine radiography for monitoring is not Management of spondyloarthritis focuses on treatment of inflam recommended. mation and autoimmunit5r to address pain and prwent structural When a TNF inhibitor fails, patients should receive an damage. If damage has occurred, mechanical pain must be interleukin-l7 inhibitor in lieu of a second TNF agent. For addressed as well. Patient education, exercises to maintain range patients with significant peripheral arthritis, sulfasalazine is of motion and control weight, and modilication of diet and life- recommended over methotrexate and can be added to the style habits to prevent cardiovascular disease are vital. biologic agent if needed. However, these agents have little or no ellect on axial disease. Ankylosing Spondylitis Uveitis is generally treated with topical glucocorticoids. Figure 28 details recommendations for initial treatment of For severe or frequent recurrences, the TNF inhibitors adali- active ankylosing spondylitis. NSAIDs are recommended as mumab or infliximab can be considered. Etanercept, an anti initial medication for most patients with ankylosing spondylitis TNF receptor fusion protein, is effective for the spine but because they relieve pain and improve stiffness. Given the probably not eye disease. unique potential for disease modiflzing effects (oniy in ankylos- Physical therapy to maintain general range of motion is ing spondylitis), the American College of Rheumatolo$/ (ACR) essential. Patients with damage to hip or shoulder joints may conditionally recommends continuous NSAID use (rather than require total joint arthroplasty, which may dramatically on demand use) for patients with active disease. Higher and improve function and quality of life. Assess for additional lsolated sacroiliitis Axial disease disease manifestations or enthesitis

f,EY P0lI|TS {ontinued) long-term doses of anti inflammatory agents (e.g., naproxen, . In psoriatic arthritis radiographic findings take the form 500 mg twice daily; piroxicam, 20 mg daily) are required to modi$r new bone formation and decrease inflammation. A dose of erosions of the distal head of the proximal joint and juxta-articular new bone formation at the proximal of a longer acting NSAID at dinnertime can make the patient comfortable throughout the night and into the moming. head of the distal joint, leading to a "pencil in cup" According to the 2019 ACR guidelines, patients in whom appearance across the joint. NSAIDs fail can be treated with a tumor necrosis factor (TNF) inhibitor. Numerous randomized controlled trials have shown improvements in clinical, radiographic, and MRI outcomes in Management patients with active ankylosing spondylitis taking TNF inhibi General Considerations tors. Routine serial spine radiography for monitoring is not Management of spondyloarthritis focuses on treatment of inflam recommended. mation and autoimmunit5r to address pain and prwent structural When a TNF inhibitor fails, patients should receive an damage. If damage has occurred, mechanical pain must be interleukin-l7 inhibitor in lieu of a second TNF agent. For addressed as well. Patient education, exercises to maintain range patients with significant peripheral arthritis, sulfasalazine is of motion and control weight, and modilication of diet and life- recommended over methotrexate and can be added to the style habits to prevent cardiovascular disease are vital. biologic agent if needed. However, these agents have little or no ellect on axial disease. Ankylosing Spondylitis Uveitis is generally treated with topical glucocorticoids. Figure 28 details recommendations for initial treatment of For severe or frequent recurrences, the TNF inhibitors adali- active ankylosing spondylitis. NSAIDs are recommended as mumab or infliximab can be considered. Etanercept, an anti initial medication for most patients with ankylosing spondylitis TNF receptor fusion protein, is effective for the spine but because they relieve pain and improve stiffness. Given the probably not eye disease. unique potential for disease modiflzing effects (oniy in ankylos- Physical therapy to maintain general range of motion is ing spondylitis), the American College of Rheumatolo$/ (ACR) essential. Patients with damage to hip or shoulder joints may conditionally recommends continuous NSAID use (rather than require total joint arthroplasty, which may dramatically on demand use) for patients with active disease. Higher and improve function and quality of life. Assess for additional lsolated sacroiliitis Axial disease disease manifestations or enthesitis Continuous NSAIDs Peripheral-predominant NSAIDs and active, land-based disease physical therapy

Assess for additional lsolated sacroiliitis Axial disease disease manifestations or enthesitis Continuous NSAIDs Peripheral-predominant NSAIDs and active, land-based disease physical therapy Symptoms controlled? NSAIDs Symptoms controlled? Yes No Yes No Symptoms controlled? Continuous Local glucocorticoid NSAIDs injections (avoid Continuous Add TNF Achilles tendon, patella, NSAIDs inhibitor Yes No and quadriceps) Continuous <2 joints NSAIDs Symptoms controlled? Yes No Yes No Local glucocorticoid Sulfasalazine injections Continue TNF Switch to inhibitor secukinumab or ixekizumab FIGURE 28. Recommendationsfortheinitialtreatmentofactiveankylosingspondylitis.INF=tumornecrosisfactor. 41