Ankylosing spondylitis

Ankylosing Spondylitis

Important History Taking Points:

- Symptoms: Inquire about chronic back pain, stiffness, and reduced mobility, especially in
the morning or after periods of inactivity. Pay attention to pain in the buttocks, hips, and
shoulders. Note if the pain improves with exercise, but does not fully resolve.
- Dietary habits: Ask if the patient follows any specific dietary plans or restrictions.
- Drug history: Determine if the patient has taken any medications for pain management or
inflammation, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids.
- Family history: Assess if any first-degree relatives, such as parents or siblings, have been
diagnosed with ankylosing spondylitis.
- Other pertinent history: Inquire about eye inflammation (uveitis), bowel symptoms
(inflammatory bowel disease), or other related conditions.

Explanation of significance:
- Chronic back pain and stiffness are hallmark symptoms of ankylosing spondylitis. These
symptoms typically last for more than three months and improve with exercise but not rest.
- Dietary habits may provide insights into potential triggers or aggravating factors for the
condition.
- Drug history helps determine if the patient has tried any medications that could provide
relief or help manage symptoms.
- Ankylosing spondylitis has a strong genetic component, so a family history is significant.
- Other related conditions, such as uveitis and inflammatory bowel disease, may coexist
with ankylosing spondylitis.

Red Flags:
1. Severe and worsening back pain not relieved by rest.
2. Rapidly progressive deformity of the spine.
3. Severe or unexplained weight loss.
4. Neurological symptoms, such as weakness or numbness in the extremities.
5. Loss of bowel or bladder control.
6. Severe morning stiffness lasting for more than one hour.
7. Chest pain or difficulty breathing.

Explanation of significance:
- These red flags indicate potential complications or serious conditions associated with
ankylosing spondylitis, such as spinal fractures, spinal cord compression, infection, or
cardiac involvement.
- Urgent medical evaluation is needed if any of these symptoms occur to prevent further
damage or complications.
Predisposing Factors:
1. Genetic predisposition: Ankylosing spondylitis has a strong genetic component, with
certain human leukocyte antigen (HLA) genes, such as HLA-B27, being strongly associated.
2. Gender: Males have a higher risk of developing ankylosing spondylitis compared to
females.
3. Age: Symptoms often begin between late adolescence and early adulthood.
4. Family history: Having a first-degree relative with ankylosing spondylitis increases the
risk.

Explanation of significance:
- Genetic predisposition plays a significant role in the development of ankylosing
spondylitis.
- Gender and age provide additional risk factors for the condition.
- Family history is an important factor as it increases the likelihood of an individual
developing the disease.

Important Investigations:
1. Blood tests: These may include an HLA-B27 test, erythrocyte sedimentation rate (ESR),
and C-reactive protein (CRP) to assess inflammatory markers and help with diagnosis.
2. Imaging: X-rays of the sacroiliac joints and spine can show characteristic changes.
Magnetic resonance imaging (MRI) is more sensitive in early disease detection.
3. Referral for further investigations: If symptoms are severe or complications are
suspected, referral for specialized imaging, such as computed tomography (CT) or
ultrasound, may be necessary.

Rationale:
- Blood tests help identify inflammatory markers and the presence of HLA-B27, which aids
in the diagnosis of ankylosing spondylitis.
- X-rays and MRI are useful in visualizing structural changes in the sacroiliac joints and
spine.
- Specialized imaging may be required for detailed evaluation or if there is concern for
complications.

Treatment Available:
1. Nonsteroidal anti-inflammatory drugs (NSAIDs): These medications help relieve pain and
reduce inflammation. Examples include ibuprofen and naproxen.
- Primary care management: NSAIDs are often the first-line treatment for mild to
moderate symptoms of ankylosing spondylitis. They should be taken regularly as
prescribed.
2. Disease-modifying antirheumatic drugs (DMARDs): In severe cases or inadequate
response to NSAIDs, DMARDs such as sulfasalazine or methotrexate may be prescribed to
reduce disease activity and slow progression.
3. Biologic agents: In more severe disease, biologic therapies like tumor necrosis factor
(TNF) inhibitors (e.g., adalimumab, etanercept) can be used to target specific inflammatory
pathways.
- Referral to appropriate specialists (rheumatologists): Referral is necessary for initiation
and monitoring of biologic therapies.

Explanation:
- NSAIDs help manage pain and inflammation in mild to moderate cases and are generally
well-tolerated.
- DMARDs and biologic agents are used in moderate to severe disease to slow disease
progression and alleviate symptoms.
- Referral to a rheumatologist is important for specialized management and initiation of
biologic therapies.

When and Who to Refer To:

- Referral to a rheumatologist is recommended for confirmation of diagnosis, initiation and
monitoring of DMARDs or biologic therapies, and management of complex cases.
- Referral to an ophthalmologist is necessary if uveitis (inflammation of the eye) is
suspected or develops.

When to Refer to the Emergency Department:

- Severe worsening back pain not relieved by rest.
- Neurological symptoms, loss of bowel or bladder control, or other signs of spinal cord
compression.
- Severe chest pain or difficulty breathing.

Explanation:
- These symptoms may indicate serious complications that require immediate medical
attention to prevent further damage or potential life-threatening situations.

Important Links:
- [Patient Information Leaflet - Ankylosing Spondylitis](https://www.rheumatology.org/I-
Am-A/Patient-Caregiver/Diseases-Conditions/Ankylosing-Spondylitis)
- [National Ankylosing Spondylitis Society](https://nass.co.uk/)

Self-care advice:
- Regular exercise, including stretching and posture-improving activities.
- Use heat or cold therapy to manage pain and stiffness as needed.
- Maintain good posture and avoid prolonged periods of inactivity.
- Practice relaxation techniques to help manage stress.
- Follow a healthy and balanced diet to support overall well-being.
- Follow the prescribed medication regimen and attend regular follow-up appointments.

Safety netting advice:

- If experiencing severe worsening pain or new neurological symptoms, go to the
Emergency Department or call an ambulance.
- Contact your rheumatologist if there are any concerns regarding medication side effects or
disease progression.
- If uveitis symptoms develop (eye redness, pain, or visual changes), seek immediate
ophthalmology consultation.
- If chest pain or difficulty breathing occurs, seek emergency medical attention or call
emergency services.
- Avoid driving if symptoms significantly impair mobility or cause safety concerns.