Managing your Inflammatory Back Pain Dr Amanda Isdale Rheumatologist York Teaching Hospital

Inflammatory Back Pain Presenting symptom of the Axial Spondyloarthropathy spectrum of diseases Chronic- more than 3/12 Gradual onset before age 45 years Relieved by exercise, no improvement with rest Relieved by NSAIDs

Estimated proportion of affected individuals* Time Spectrum of Axial Spondyloarthritis Axial SpA (ASAS criteria) Ankylosing Spondylitis (modified New York criteria) Patients with chronic back pain ≥3 months and aged <45 years Non-radiographic stage X-ray-negative MRI positive sacroiliitis MRI negative, HLA-B27-positive** Radiographic stage X-ray-positive sacroiliitis Radiographic stage X-ray-positive sacroiliitis and/or spinal changes*** * Heights reflect an estimate of the proportion of patients in each group ** Clinical arm if non-radiographic axial SpA *** Radiographic evidence if inflammatory spinal changes including i.e., syndesmophytes, fusion or posterior element involvement

Delays in diagnosis 15% of UK primary care population meet criteria for IBP Mean delay in diagnosis 8.57 years WHY? Patients not bothering to see GP- see other AHPs Failure to recognise symptoms Failure to image appropriately Belief that can be managed in primary care (35% of GPs)

But many common needs Getting the right diagnosis! Mechanical vs inflammatory vs other conditions; Non- radiographic axial SpA vs AS Seeing a specialist team Getting the right information Understanding the diagnosis Accepting the diagnosis Taking ownership

Management needs to tailored to an individual Dependent on: Stage of disease Severity of disease Activity of the disease General health of the patient Presence of other medical conditions Response and tolerance of pharmaceutical interventions

You have Axial SpA/AS Active vs passive acceptance Positive vs negative attitude Understanding your condition- reading the recommended PILs etc Seeking help when needed Accepting medication may be necessary Helping yourself

Lifestyle changes Stop smoking- known to result in poorer outcome and adverse effects on general health Lose weight if necessary aiming for healthy weight for height Avoid a sedentary lifestyle Listen to and follow the advice of your specialist team- particularly the physio Adjust work, hobbies and sport if required Invest in a good bed

The potential legacy of the disease without effective treatment

What happens to the spine in AS? The spine is like a suspension bridge It flexes and extends and is able to transmit and distribute force Remember Newton’s cradle with the 5 hanging balls? If it can’t move, it can’t transmit and distribute force

Getting the foundation right: Early disease Specialist Physiotherapy- exercise & stretching. Group sessions are better than individual: NASS classes, hydro sessions, Pilates classes, aqua- aerobics etc Adequate pain and anti-inflammatory relief to engage in the physio programme May require IM steroid to reduce inflammation or sometimes injection of steroid to the sacroiliac joints Managing fatigue

Established Spinal Disease: AS Physio exercises & stretching NSAIDs & analgesics Using IM steroid for flares Assessing for osteoporosis Identifying fracture vs flare Managing eg hip disease with replacement

Other non-spinal considerations Peripheral joints & entheses Eye disease: uveitis- can occur at any time, usually 1 eye at a time; generally better on anti-TNF Gut disease: NSAID related; Inflammatory bowel disease- may present insidiously Skin: psoriasis Cardiovascular: heart valve disease; arrhythmias etc

Management Spine: Failure of Standard Interventions If there is poor response to these interventions; assess for biologic agents Anti-TNF( Etanercept, Adalimumab, Golimumab, Certolizumab) Require measures of active disease (BASDAI & pain >4) on 2 occasions 3/12 apart + use of 2 full strength NSAIDs +other non AxSpA criteria for use

To ponder Anti-TNF:effective disease modifying but not curative therapies New biologics on stream targetting different pathways Biosimilars- cheaper (slightly), ?similar Remission? Early treatment better outcomes. When to reduce/stop? What can we afford in the future? Not everyone needs anti-TNF- getting the right balance but not missing the boat

Summary Early diagnosis is essential Self management & taking ownership of your condition are of paramount importance Exercise, stretching & lifestyle adjustments are still the foundation stones Biologic drug treatment has been a major advance but are not a cure & they can have limitations