1. All great thanks to ALLAH, greatest of all, for the countless gifts.

2. SpA patient education: Tough questions your patients might ask you By Dr. Soha H. Senara MD. Fayoum University

3. What is the meaning of patient education?

4. PE comprises all educational activities provided for patients, including aspects of therapeutic education, health education and health promotion. Patients have been recognized as active agents in managing their illness and own healthcare.

5. The principle of ‘shared decision making’ allowing patients and their providers to make healthcare decisions together, based on the best scientific evidence available, as well as the patient’s values and preferences, is increasingly accepted.

6. As an integral part in established recommendations for the management of early arthritis and ankylosing spondylitis (AS); Patient education (PE) and answering their tough questions are highly recommended.

7. The primary and main goal of accurate answer to these questions and continuous PE is no longer only knowledge transfer and disease control, but also to enable patients to manage their illness, improve their psychological state, adjust to their condition and maintain quality of life.

8. EULAR, 2015 recommendations for patient education for people with inflammatory arthritis (IA) concluded eight evidence-based and expert- opinion-based recommendations for PE for people with IA

9. Recommendation 1: PE as an integral part of standard care Patient education should be provided for people with inflammatory arthritis as an integral part of standard care in order to increase patient involvement in disease management and health promotion

10. Recommendation 2: PE throughout the course of the disease All people with inflammatory arthritis should have access to and be offered patient education throughout the course of their disease including as a minimum; at diagnosis, at pharmacological treatment change and when required by the patient’s physical or psychological condition.

11. Recommendation 3: tailored and needs- based PE The content and delivery of patient education should be individually tailored and needs-based for people with inflammatory arthritis

12. Recommendation 4: modes of delivery of PE Patient education in inflammatory arthritis should include individual and/or group sessions, which can be provided through face-to-face or online interactions, and supplemented by phone calls written or multimedia material

13. Recommendation 5: theoretical framework and evidence for PE Patient education programmes in inflammatory arthritis should have a theoretical framework and be evidence- based, such as self-management, cognitive behavioural therapy or stress management

14. Recommendation 6: outcomes of PE The effectiveness of patient education in inflammatory arthritis should be evaluated and outcomes used must reflect the objectives of the patient education programme

15. Recommendation 7: competency in delivery of PE Patient education in inflammatory arthritis should be delivered by competent health professionals and/or by trained patients, if appropriate, in a multidisciplinary team

16. Recommendation 8: training competency for delivering PE Providers of patient education in inflammatory arthritis should have access to and undertake specific training in order to obtain and maintain knowledge and skills

17. conclusion

18. In conclusion, eight evidence-based and expert-opinion-based recommendations for PE for people with IA were developed. I think we need to evaluate them to ensure relevance and effective application in our societies.

19. Spondyloarthritis (SpA )

20. قسم الروماتيزم والتاهيل اسم المريض :..................................................................... التاريخ :.......................................................................... السن :............................................................................... العنوان :........................................................................... المهنة :.................................... رقم التليفون :.................................. الايميل :.................................................................. الحالة الاجتماعية................................................................................................................................... الشكوى :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... اسئلة تريد الاجابة عليها فيما يخص شكواك اوالعلاج او غيرة....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................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21. We have to Learn how to answer our patients’ tough questions

22. 5: theoretical framework and evidence for PE 1: PE as an integral part of standard care 2: PE throughout the course of the disease 4: modes of delivery of PE 6: outcomes of PE 3: tailored and needs-based PE 8: training competency for delivering PE 7: competency in delivery of PE

23. In ACR conference, 2015 Dr. Robert Inman gave an excellent talk on SpA in an engaging format of questions and answers with case- based examples and supporting data. I'll try to summarize some of the pearls from this talk based on questions all of us have heard from our patients. Robert Inman, MD, Professor of Medicine and Immunology at University Health Network and University of Toronto

24. I agree with dr. Inman who said that we need enhancing quality of life and functioning for our patients,” SO, Structuring like this session around the questions that patients ask us rather than the questions physicians ask each other is keeping patient well-being at the center of the discussion.

25. What can I eat, Which type of food suitable for my disease? This is a very common question for which we have no good answer,” Dr. Inman said. One of the most common questions involves the relationship, if any, between spondyloarthritis and diet. There are multiple opinions but few data and even less consensus.

26. “It raises the question as to whether there is subclinical bowel inflammation. There is some evidence that more than half of patients with ankylosing spondylitis have some clinical bowel inflammation. Ten percent have overt Crohn’s disease or ulcerative colitis.

27. There is some indication that asymptomatic inflammatory bowel disease is more common than we recognize in spondyloarthritis, but even in the IBD literature there is no consensus on diet.” Patients often try multiple diets to manage their symptoms, including gluten-free, lactose-free, low carbohydrate, high carbohydrate, and more.

28. Patients typically ask if their disease can be managed using NSAIDs alone, Dr. Inman said, a common question for patients who are taking only NSAIDs. If I have to discontinue NSAIDs, what are my options?

29. Should I consider a biologic? What is the best time to start biologic therapy? Meta-analyses show with no doubt that all TNF inhibitors demonstrate a significant effect vs placebo in symptoms and quality of life. There is controversy regarding disease progression. However, studies shows that early use of TNFi reduced the rate of radiographic progression.

30. What if biologics are not an option? This is a big problem. There is data that RTX has some effect, and although it is less than a TNFi, it is acceptable. One pearl: Remember that psoriasis can be induced by TNFi's (anti-TNF induced palmoplantar psoriasis). Ustekinumab can work in this situation. Dr. Inman said

31. The usual follow up is a series of questions about new drugs. Biologic therapy

32. Comorbidities are another common area of concern. Patients have likely read about the potential risks of infection or cancer associated with biologic therapy or cardiovascular risks with certain NSAIDs, but they may not have read the most recent findings or may not read too much into a particular study that does not match their particular disease or treatment regimen.

33. Howevere, We have data on things like the risks of nonsteroidals on cardiovascular disease and the risks of a biologic on cancer or opportunistic infection,” he said. We have some very good data on some of these common questions.”

34. Should I have surgery for my hips? THR is the most common procedure offered to AS patients with damaged hips and they do well. Back surgery in cases of severe progressive thoracic kyphosis can be successful if done in centers with established expertise in working with such AS patients.

35. Should I consider pregnancy? “From women with AS there are commonly questions about the impact of pregnancy on the course of AS, and the management of their AS during the course of the pregnancy,” he said. Back pain improves early and gets worse later in pregnancy, just like in non-AS controls. NSAIDs can be safely used in the first 2 trimesters until week 30, when they should be stopped due to premature closure of the ductus and possible reduction in amniotic fluid volume.

36. “A related concern is the likelihood that their kids will also be affected by AS. What are the chances of passing AS to my child? These questions, if left unanswered, can also be a source of anxiety for the patients.” There is a 90% likelihood the child will not have AS therefore go forth and multiply!

37. One of the most often-ignored areas is emotional impact of the spondyloarthritis. Patients may ask about mood swings but seldom ask about underlying emotional issues.

38. “These are primarily young people, so depression and anxiety around their disease is an important part of the discussion,” Dr. Inman said. It’s a big issue to think that you’ve got a chronic illness, especially when we’re superimposing the issue of a biologic.

39. Please, be patient and listen carefully to your patient Please don’t ignore his questions; answer and answer kindly even tough and silly ones. Please, imagine him father, mother, sister, brother….. and Feel his feeling to fight with him against his and your enemies; disease, poverty and ignorance.

40. Thank you