Recognition and Management of Inflammatory Advisor/consultant: - - PowerPoint PPT Presentation

12/15/2018 1

Recognition and Management of Inflammatory Back Pain: Essentials for Primary Care Providers

Lianne S. Gensler, MD

University of California, San Francisco

Disclosures

• Advisor/consultant: Galapagos, Janssen, Lilly
• Research grant/support: Amgen, Novartis, Pfizer, UCB

Case

• A 27-year-old woman with low back pain that started 2 years
• ago. She experienced initially alternating “hip” pain, worse in

the morning, with stiffness lasting 45 minutes. The pain is made better with exercise and NSAIDs.

• Pain awakens her from sleep around 4 AM and requires

getting up to take ibuprofen and stretch.

NSAIDs = nonsteroidal anti-inflammatory drugs.

Chronic Back Pain Features

NSAIDs = nonsteroidal anti-inflammatory drugs. Braun J, Inman R. Ann Rheum Dis. 2010;69:1264–1268. Braun A, et al. Ann Rheum Dis. 2011;70:1782–1787.

Feature Mechanical Inflammatory Age of onset > 40 years < 45 years Onset Acute Insidious Worst time of day End of the day Morning/ 2nd part of night Morning stiffness None or < 30 minutes > 30 minutes Nocturnal back pain When going to bed 2nd part of night Exercise / activity Usually worse Makes pain better NSAIDs improve pain 15% 80% Associated with sciatica Can be Not usually

12/15/2018 2 Inflammatory Back Pain: Hallmark Feature

Feature Odds Ratio Insidious onset 12.7 Pain at night (with improvement upon awakening) 20.4 Age at onset <40 years 9.9 Improvement with exercise 23.1 No improvement with rest 7.7 Sensitivity 79.6%; Specificity 72.4% Positive LR = 79.6/(100-72.4) = 2.9 ~Probability = 14%

LR = likelihood ratio. Sieper J, et al. Ann Rheum Dis. 2009;68(6)784-788; Rudwaleit M, et al. Ann Rheum Dis. 2009;68(6):777-783; Ozgocmen S, et al. J Rheumatol. 2010;37(9):1978.

Question

In the National Health and Nutrition Examination Survey (NHANES), chronic axial pain was found in ~20% of the population. Of these people, what percent had inflammatory back pain?

• A. 1% of the chronic back pain population
• B. 5% of the chronic back pain population
• C. 15% of the chronic back pain population
• D. >25% of the chronic back pain population

?

20% 14% 20% 46%

NHANES 2009 to 2010

• 19.2% chronic axial pain
• In patients with chronic axial pain, 28% to 35.5% had inflammatory

back pain (IBP)

• US prevalence of IBP: 5% to 6%

Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64(6):905-910. Weisman MH, et al. Ann Rheum Dis. 2013;72(3):369-373.

• Self-reported prevalence of ankylosing spondylitis = 0.55

*SpA = spondylarthritis; NHANES = National Health and Nutrition Examination Survey; CI = confidence interval; ESSG = European Spondylarthropathy Study Group.

†Estimates were age adjusted to the midpoint of the current population survey estimate

for the 2010 US civilian population. For race/ethnicity, only data for the major US subgroups are shown.

Prevalence of SpA in US adults 20 – 69 years of age: the NHANES 2009–2010*

Case type Total population sampled Number of SpA cases Prevalence, % SE 95% CI ESSG SpA (Overall†)

5,103 70 1.4 0.2 1.0–1.9

Rheumatoid Arthritis versus Spondyloarthritis

* In US adults aged 20 to 69 years in the NHANES 2009-2010. ** Helmick CG, et al. Arthritis Rheum. 2008;58(1):15-25. Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64(6)905-910.

0.6 0.52- 0.55 1.4

0.2 0.4 0.6 0.8 1 1.2 1.4 1.6

Prevalence

Rheumatoid Arthritis** Ankylosing Spondylitis Spondyloarthritis (Axial)* %

12/15/2018 3 Case 2: Your Next Step Is To…

27-year-old woman with low back pain that started 4 months ago. Initially alternating “hip” pain, worse in the AM w/ stiffness lasting 45 mins. The pain is made better with exercise and NSAIDs. Pain awakens him from sleep around 4 AM and requires him to get up, take ibuprofen, and stretch.

• A. Check HLA B27
• B. Check ESR / CRP
• C. Order imaging study
• D. Obtain additional history

?

9% 23% 26% 42%

Your Next Step Is To…

• Evaluate for other symptoms:

– Peripheral joint pain, heel pain, chest wall pain, bloody stools/

diarrhea, rashes

• Evaluate for other diagnoses:

– Acute anterior uveitis, Crohn’s disease, ulcerative colitis, psoriasis

• Assess family history:

– ~20% AS patients have a first-degree relative with AS – Cross relative risk in AS and IBD = 3.0

AS = ankylosing spondylitis. Thjodleifsson B, et al. Arthritis Rheum. 2007;56(8):2633-2639.

Case (continued)

• A 27-year-old woman with IBP:

– The patient tells you that her father has psoriatic arthritis

• How does this additional data change your assessment?

AS in Chronic Low Back Pain Population 5% Inflammatory back pain LR 3.1

3.1 multiplied by 5.1 gives a likelihood product of 15.81. Family history LR 15.81 x 6.4 = 101.

Elevated acute phase reactants LR 2.5

Heel pain (enthesitis) LR 3.4 Peripheral arthritis LR 4.0 Dactylitis LR 4.5 Acute anterior uveitis LR 7.3 Positive family history LR 6.4 Good response to NSAIDs LR 5.1 HLA-B27 LR 9.0 MRI LR 9.0 LR 15.81 Probability = 45% LR 101 Probability = 84%

Pr =

98%

Probability of Spondyloarthritis Using Multiple Clinical and Lab Features

HLA-B27 = human leucocyte antigen-B27; LR = likelihood ratios; Pr = Probability. Rudwaleit M, et al. Arthritis Rheum. 2005;52(4):1000-1008.

BB8

Slide 12 BB8 The figure has elements from Fig 3 in the referenced article, but is not the same. No permission needed.

Betti Bandura, 5/17/2017

12/15/2018 4

Axial Spondyloarthritis: sacroiliitis and spondylitis

Psoriasis Psoriasis

Spondyloarthritis: Family of Diseases

Hochberg M, et al. In: Rheumatology. 6th ed. St. Louis, MO: Mosby; 2014:Sec 9; Ch 114, 946-950.

25% to 40%

5% to 10% Subclinical Colitis 25% to 60%

10% Inflammatory Bowel Disease Inflammatory Bowel Disease Acute Anterior Uveitis Acute Anterior Uveitis

Extra-articular manifestations & comorbidities

Back pain

Sacroiliitis on MRI

Back pain

Radiographic sacroiliitis

Back pain

Syndesmophytes

DIAGNOSIS

Axial Spondyloarthritis

Rudwaliet M, et al. Arthritis Rheum. 2005;52(4):1000-1008.

Non-radiographic stage Radiographic stage Time (years)

Age at First Symptoms and at First Diagnosis in Ankylosing Spondylitis Patients

Feldtkeller E, et al. Curr Opin Rheumatol. 2000;12(4):239-247.

Age at first symptoms Age at first diagnosis 920 males 476 females

100 80 60 40 20

Cumulated percentage of patients

Age in years

10 20 30 40 50 60 70 Average delay in diagnosis: 9 years

The Axial SpA Spectrum

Ankylosing Spondylitis Non-radiographic Axial Spondyloarthritis Radiographic sacroiliitis Bamboo spine DAMAGE

(Milder disease Or Early disease)

Modified NY Criteria

ASAS = Assessment of SpondyloArthritis International Society; SpA = spondyloarthritis. Helmick CG, et al. Arthritis Rheum. 2008;58(1):15-25. Reveille JD, et al. Arthritis Rheum. 2012;64(5):1407-1411. Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64(6)905-910.

ASAS Axial SpA Criteria

12/15/2018 5

The Axial SpA Spectrum

Features Axial Spondyloarthritis Ankylosing Spondylitis Non-radiographic Axial Spondyloarthritis Gender (M:F) 1:1 2-3:1 1: 1-2 HLA-B27

• 85%

60% Prevalence 1.4% .55%

• Damage on

x-ray Variable Always Mild possible but not required Inflammation

• n MRI

Variable Possible but not necessary Always for classification

Lee W, et al. Ann Rheum Dis. 2007;66(5):633-638. Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64(6):905-910.

Axial Spondyloarthritis Epidemiology

• Age of Onset: ~24 years (up to 45 years old)
• Prevalence: Follows prevalence of HLA-B27
• HLA-B27

– Ethnicity

High: Inuit and Scandinavians Low: Sub-Saharan Africans, Australian Aboriginals, Japanese

axSpA = axial spondyloarthritis. Boyer GS, et al. J Rheumatol. 1994;21(12):2292-2297; Feldtkeller E, et al. Curr Opin Rheumatol. 2000;12(4):239-247; Lee W, et al. Ann Rheum Dis. 2007;66(5):633-638; Tikly M, et al. Curr Rheumatol Rep. 2014;16(6):421.

HLA-B27 in the US Population

Reveille JD, et al. Arthritis Rheum. 2012;64(5):1407-1411. *For race/ethnicity, only data for the major subgroups in the US are shown, which therefore do not sum to the overall sample

• size. All race/ethnicities are included in the overall prevalence estimates and in the prevalence estimates by sex and age. ‡P<.01

versus all other race/ethnic groups combined. §P<.05 versus non-Hispanic white persons. ¶Estimates do not meet criteria for statistical stability.

Sample Prevalence Selected characteristics

• No. Positive for

HLA-B27 Total Population % (95% CI) Overall US prevalence 124 2,320 6.1 (4.6, 8.2) Sex Male Female 53 71 1,123 1,197 5.8 (3.9, 8.4) 6.5 (4.7, 8.9) Race/ethnic group Non-Hispanic white Mexican American Non-Hispanic black 79 27 4 1,021 622 345 7.5 (5.3, 10.4)± 4.6 (3.4, 6.1)§ 1.1 (0.4, 3.1)¶ Prevalence of HLA-B27 in US Adults Aged 20-69 Years, by Selected Characteristics. 2009 Data.

Referral Strategy

van Hoeven L, et al. PloS One. 2015;10(7):e0131963.

Pooled dataset sensitivity and specificity of referral rule 75% and 58%

BB18

Slide 20 BB18 Published (Figure 2). No permission necessary under the Creative Commons License CC BY 4.0.

Betti Bandura, 5/17/2017

12/15/2018 6 Rheumatology Referral Recommendations

• Inflammatory back pain
• HLA-B27
• Sacroiliitis on imaging
• Peripheral manifestations (synovitis, enthesitis and/or dactylitis)
• Extra-articular manifestation (psoriasis, IBD and/or uveitis)
• Positive family history for spondyloarthritis
• Good response to NSAIDs
• Elevated acute phase reactants (ESR and/or CRP)

Poddubnyy D, et al. Ann Rheumatic Dis. 2015;74(8):1483-1487.

Patients with chronic back pain (≥3 months) with onset age <45 years should be referred to rheumatology if any of the following is present:

Imaging in Axial Spondyloarthritis

Radiation Exposure Benefit Limitation Radiographs 0.6/1.5 mSv + damage (erosions/new bone) Insensitive early in disease (first 10 years) MRI pelvis

• + inflammation best; no gad

needed; structural changes helpful $$$; correct protocol and trained MSK radiologist CT scan 10-15 mSv Shows damage best $$; radiation Bone Scan 6 mSv Nonspecific Not specific; $; radiation

• Start with anteroposterior pelvis
• If negative for sacroiliitis, order MRI of the pelvis without contrast – T1,

STIR/T2 fat-suppressed images with coronal oblique views

Gad = gadolinium; MSK = musculoskeletal; STIR = short-tau inversion recovery. Mettler FA Jr, et al. Radiology. 2008;248(1):254-263.

Axial Spondyloarthritis Imaging

Normal sacroiliac joints Ankylosis of the sacroiliac joints and spine MRI with inflammation (bone marrow edema) = sacroiliitis

SI Joint Bone Marrow edema in Athletes

Weber U et al. Arth & Rheumatol Vol. 0, No. 0, Month 2018, pp 1–11 DOI 10.1002/art.40429

12/15/2018 7 Summary

• Prevalence of axial spondyloarthritis >1%
• Delay to diagnosis of years – back pain common & x-rays take

time to develop damage

• Hallmark feature: Inflammatory back pain
• Should be considered with back pain before age of 45 years
• Obtain history, consider imaging, HLA B27, and inflammatory

markers when appropriate

• Imaging work up includes plain radiographs

+/- MRI sacroiliac joints, not lumbar spine

Effective Strategies for Managing AxSpA in the Primary Care Setting

Case

A 25-year-old with recent Axial Spondyloarthritis (AxSpA) diagnosis (x- rays neg, +MRI, high CRP) returns to clinic He tells you he is having 60 mins of morning stiffness and wakes up at 4 am in pain. He is taking ibuprofen 600 mg TID. Besides referral to rheumatology, your next step:

• A. Start Prednisone
• B. Start Methotrexate
• C. Try another NSAID
• D. Start a TNF inhibitor

?

34% 6% 32% 28%

Ward MM, et al. Arthritis Rheumatol. 2016;68(2):282-98.

12/15/2018 8

Or consider changing to an IL-17A inhibitor*

Ward MM, et al. Arthritis Rheumatol. 2016;68(2):282-98. *van der Heijde D, et al. Annals of the Rheumatic Diseases Published Online First:13 January 2017. doi: 10.1136/annrheumdis-2016-210770

Case

A 31-year-old man with a recent axial spondyloarthritis (axSpA) diagnosis (X-rays with sacroiliitis and normal CRP) returns to clinic He tells you he is having morning stiffness that resolves in minutes. He has no night pain. He is exercising regularly and taking naproxen 500 mg a couple of times per week. Besides referral to rheumatology, your next step is to:

A.

Recommend a daily dose of naproxen to prevent damage

B.

Start methotrexate and folate

• C. Start an TNF inhibitor
• D. Refer to physical therapy

CRP = C-reactive protein; TNF = tumor necrosis factor.

?

23% 74% 4% 0%

Stable Axial SpA

AS = ankylosing spondylitis; ESR = erythrocyte sedimentation rate; NSAIDs = nonsteroidal anti-inflammatory drugs; SpA = spondyloarthritis; TNFi = tumor necrosis factor inhibitors. Ward MM, et al. Arthritis Rheumatol. 2016;68(2):282-98. Because non-radiographic axial SpA has only recently been defined, literature on treatment of this condition is limited. Recommendations were the same as for AS.

Physical Therapy and Exercise

• Physical therapy meta-analysis showing benefit
• Exercise improves function
• Tai chi improves disease activity and flexibility
• Back exercises improve disease activity
• Aerobic and pulmonary exercise

Dagfinrud H, et al. Cochrane Database Syst Rev. 2008;Jan 23(1):CD002822; Brophy S, et al. Semin Arthritis Rheum. 2013;42(6):619-26; Lee EN, et al. Evid Based Complement Alternat Med. 2008;5(4):457-62; Fernandez-de-Las-Peñas C, et al. Am J Phys Med Rehabil. 2006;85(7):559-67. Ince G, et al. Phys Ther. 2006;86(7):924-35.

12/15/2018 9 Case

A 31-year-old man with a recent axSpA diagnosis (X-rays with sacroiliitis and normal CRP) now returns to clinic He tells you he is having 60 minutes of morning stiffness and wakes up at 4 am in pain. He is now taking naproxen 500 mg twice a day. Besides referral to rheumatology which he is still waiting for, your next step is to:

• A. Start prednisone
• B. Start methotrexate
• C. Try another NSAID
• D. Start an TNF inhibitor

?

0% 0% 0% 0%

NSAID Algorithm for AxSpA

• NSAIDs are the first-line therapy in axSpA unless

contraindicated

• It is recommended that 2 full-strength NSAIDs be tried

before advancing to a biologic

• Clinical experience: Extended release formulations may

work better than short acting NSAIDs, particularly at night when patients are sleeping*

Ward MM, et al. Arthritis Rheumatol. 2016;68(2):282-98. * Personal experience, Lianne Gensler, MD

Efficacy of NSAIDs in AxSpA

• AxSpA versus mechanical back pain

Amor B, et al. Rev Rhum Engl Ed. 1995;62(1):10-5.

10 20 30 40 50 60 70 80 Ankylosing Spondylitis Mechanical back pain

Response to NSAIDs

N=69 N=768

Nonsteroidal Anti-inflammatory Drugs

Song IH, et al. Arthritis Rheum. 2008;58(4):929-38.

Drug Half-life (Hours) Typical Dosing Maximum Dose (mg) Naproxen 10-18 BID 1000 Ibuprofen 1.8-3.5 TID-QID 2400-3500 Meloxicam 20 QD 15 Piroxicam 30-60 QD 20 Diclofenac (XR) 2 (6.75) TID 150 Etodolac (ER) 6.4 (8.4) BID 800 Indomethacin (XR) 2 (4.5) TID (BID) 150 Celecoxib 8-12 BID 400

12/15/2018 10 NSAIDs and Cardiovascular Risk

• AS patients appear have a higher risk of MI and stroke (meta-

analysis)1

• PRECISION Trial: At moderate doses, celecoxib was found to be

non-inferior to ibuprofen or naproxen with regard to cardiovascular safety2

• NSAIDs may be cardio-protective in AS. Lower risk of vascular mortality in

those taking NSAIDs

1 Mathieu S, et al. Semin Arthritis Rheum. 2015;44(5):551-5. 2 Nissen SE, et al. N Engl J Med. 2016;375(26):2519-29. 3 Coxib and traditional NSAID Trialists' (CNT) Collaboration. Lancet. 2013; 382(9894): 769–779.

Therapies that do not Work in AxSpA

• Systemic Glucocorticoids
• DMARDs – methotrexate

ASDAS = Ankylosing Spondylitis Disease Activity Score; BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; BASFI = Bath Ankylosing Spondylitis Functional Index; BASMI = Bath Ankylosing Spondylitis Metrology Index; DMARDs = disease-modifying antirheumatic drugs. Haibel H, et al. Ann Rheum Dis. 2014;73(1):243-6. Haibel H, et al. Ann Rheum Dis. 2007;66(3):419-21.

Case (continued)

The patients returns 1 month later on a full-dose of a second NSAID and notes that the pain and stiffness have resolved, but he is now having frequent diarrhea. Your next step is to:

• A. Order a stool culture
• B. Evaluate for Helicobacter pylori
• C. Refer for a colonoscopy
• D. Order a fecal calprotectin
• E. Start an TNF inhibitor

?

5% 7% 5% 21% 61%

Diarrhea in AxSpA

• NSAID-associated ileal or colonic

ulcers versus IBD

• NSAIDs unmask/flare IBD
• Up to 10% have definitive IBD
• Up 60% with subclinical gut

inflammation

IBD = inflammatory bowel disease. Adebayo D, et al. Postgrad Med J. 2006;82(965):186-91; De Vos M, et al. Gastroenterology. 1996;110(6):1696-703; Mielants H, et al. J Rheumatol. 1995;22(12):2266-72; Adebayo D, et al. Nat Clin Pract Gastroenterol Hepatol. 2007;4(6):347-51.

12/15/2018 11 When NSAIDs are Contraindicated

• r not Fully Efficacious
• A colonoscopy was performed and shows granulomatous

inflammation of the colon and ileum, consistent with Crohn’s disease.

• NSAIDs are stopped.
• Patient should be co-managed with Rheumatology and

Gastroenterology.

• TNF inhibitor (monoclonal antibody) is started to treat both

axSpA and Crohn’s disease.

Overview of Biologic Treatment

• Biologics only FDA approved for ankylosing spondylitis (AS)

at this time, but also used in patients with non-radiographic axial SpA

– All TNF-inhibitors (etanercept, adalimumab, golimumab,

certolizmab [SC], and infliximab [IV])

– IL-17A inhibitor (secukinumab)

SC = subcutaneous; IV = intravenous. Ward MM, et al. Arthritis Rheumatol. 2016;68:282-298; etanercept. Prescribing information. Amgen; 2016; adalimumab. Prescribing information. AbbVie Inc. 2016; golimumab. Prescribing information. Janssen Biotech, Inc. 2016; certolizumab. Prescribing information. Janssen Biotech, Inc. 2015; infliximab. Prescribing information. UCB, Inc; 2017;

• secukinumab. Prescribing information. Novartis Pharmaceuticals Corporation; 2016

AxSpA: TNFi Efficacy*

45 39 47 44 48 14 13 12 15 16 Etanercept Adalimumab Infliximab Golimumab Certolizumab

Patients achieving 40% Improvement in 5 separate trials

TNF inhibitor Placebo

Davis JC Jr., et al. Arthritis Rheum. 2003;48(11):3230-6; van der Heijde D, et al. Arthritis Rheum. 2006;54(7):2136-46; van der Heijde D, et al. Arthritis Rheum. 2005;52(2):582- 91; Inman RD, et al. Arthritis Rheum. 2008;58(11):3402-12; Landewe R, et al. Ann Rheum Dis. 2014;73(1):39-47. *All TNFi approved for AS, not nonradiographic axSpA.

IL-17A Inhibition (Secukinumab)

Two phase 3 trials of secukinumab in patients with active AS

Approved for AS, not nonradiographic axSpA (secukinumab. Prescribing information. Novartis Pharmaceuticals Corporation; 2016.) Baeten D, et al. N Engl J Med. 2015;373(26):2534-48.

12/15/2018 12 Case (continued)

The patient comes in for an urgent appointment with a new

• cough. The patient is at risk for all of the following except:
• A. Viral upper respiratory infection
• B. Community-acquired pneumonia
• C. Tuberculosis
• D. Drug-induced pneumonitis

?

11% 76% 13% 0%

Infection Prevention

• No live vaccines on biologics
• Annual inactivated influenza vaccination
• 2017 Advisory Committee on Immunization Practices (CDC)

recommendations: both pneumococcal 13-valent conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) plus booster are recommended.

13-valent pneumococcal conjugate vaccine (PCV13 [Prevnar 13] 23-valent pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax 23] Pneumococcal 13-valent conjugate vaccine. Product information. http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM201669.pdf. Accessed May 22, 2017; Pneumococcal vaccine polyvalent. Product information. http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM257088.pdf. Accessed May 22, 2017. Centers for Disease Control and Prevention. Adult Immunization Schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Accessed May 22, 2017.

Extra-articular Manifestations* & Comorbidities

IgA nephropathy amyloidosis Pulmonary fibrosis (apical) Restrictive lung disease Sleep apnea Aortitis Conduction delay Aortic insufficiency Ischemic heart disease Arachnoiditis Cauda equina syndrome Osteoporosis vertebral fractures and pseudo-fractures Depression 30% *Anterior uveitis 25% to 40% *Psoriasis 10% *IBD 5% to 10%

IgA = immunoglobulin A. Bremander A, et al. Arthritis Care Res. 2011;63(4):550-556; Klingberg E, et al. Arthritis Res Ther. 2012;14(3):R108; Berdal G, et al. Arthritis Res Ther. 2012;14(1):R19; Rudwaleit M, et al. Best Pract Res Clin Rheumatol. 2006;20(3):451-471.

Fracture in Ankylosing Spondylitis

1 year

2 4 3 6 5 2 3 4

2011 2012

12/15/2018 13

High Prevalence Osteoporosis in Ankylosing Spondylitis

Men≥ 50 yrs

• Osteoporosis

21%

• Osteopenia

44%

Klingberg E, et al. Arthritis Res Ther. 2012;14(3):R108. Vasdev V, et al. Int J Rheum Dis. 2011;14(1):68-73. Ghozlani I, et al. Bone. 2009;44(5):772-6.

43-year-old man with long standing AS 26-year-old man with 4 years AS

Fracture & Risk Assessment in AS

• Prevalence of vertebral fractures 30%
• Population studies : OR 3.26 -7.7

–Men > women with ↑after 5 yrs of diagnosis

• Fracture risk: low bone mass, ankylosis, rigidity, low BMI,

disease duration, disease activity

• Cervical spine fracture associated with AS mortality

Cooper J Rheumatol 1994; Vosse Annals Rheum Dis 2009;; Haroon NN et al Seminars Arth Rheum 2014; Siu, S et al. Arth Care & Res 2015;; D. Prieto-Alhambra et al., Osteoporos Int (2015) , Ward MM et al. Arth Rheumatol 2015; Wysham Arth Care & Res 2016

Perioperative Management (Joint replacement)

• NSAIDs — To avoid the antiplatelet effect of NSAIDs, they

should be stopped at least 3 half-lives prior to surgery (except celecoxib).

• DMARDsa should be continued in patients with rheumatic

diseases undergoing elective hip and knee replacement.

• Biologics should be withheld prior to surgery; surgery should be

planned for the end of the dosing cycle – holding 1-2 treatment

• cycles. Restart after clinical signs of wound healing, without

evidence of infection – generally recommended around 14 days.

DMARDs = disease-modifying antirheumatic drugs.

aMethotrexate, leflunomide, hydroxychloroquine, and sulfasalazine.

Goodman S et al.. Arthritis Rheumatol 2017

Summary

• First-line treatment can be initiated in primary care

– NSAIDs – Education and physical therapy referral

• Axial disease: no role for prednisone or traditional DMARDs
• Immunize patients on biologics with inactivated vaccines
• Increased risk of respiratory infections (including tuberculosis)
• Uveitis = most common extra-articular manifestation
• Common comorbidities: osteoporosis, vertebral fractures, and

cardiovascular disease