1. Ankylosing Spondylitis (ALD 27) and anti-TNF About the place of health insurance on initiation
Dr Stéphanie POUMEAUD-LAFARGE
A local survey in 2014
Department of Lot – Midi-pyrenees – France

2. Context Biotherapy Local context:
Upheaval of the management of inflammatory diseases (RA++)
Major economic burden for health insurance
Large disparity of practices in the territory
→ CNAMTS : national communication campaign
Local context:
Department with the highest proportion of patients in long- lasting affection treated by anti-TNF in 2012 (35%)

3. Objectives
To analyse the difficulties with applications on Lond During Affection for ASp for the French Health Insurance

4. Sources
All the applications for Long during affection, treated by the department of Lot
General health scheme beneficiaries
Between 01/03/2014 and 30/09/2014

5. METHODS(1)
Admission requirements Décret n° du 19 janvier 2011
Ankylosing spondylitis
Diagnostic criterias: ASAS 2009 +
Criterias of severity: HAS décembre 2008
Obvious severe disease (destructive arthritis , MICI, uveitis, cardiac involvement)
Severe and disabling disease, noticed on 2 occasions (in 3 months apart):
3 simultaneous inflammatory arthritis
BASDAI>4
BASFI>4
Continuous and optimal treatment (NSAI)
Chronic and severe disease +
Chronic treatment

6. Indication of anti-TNF (HAS 2008)
METHODS(2)
Indication of anti-TNF (HAS 2008)
Proved diagnosis
Diagnostic criterias: ASAS 2009
Active disease (2 * BASDAI > 4 in 3 months apart)
Criterias of severity: HAS décembre 2008
Severe disease
NSAI maximum recommended dose or tolerated

7. Résults Study population : 26 cases Face to face exams: 62%
Sex ratio: 1,2
Mean age: 42 years old
Refusal: 31%

8. Résults (2) Diagnostic criterias Records Inflammatory back pain
26/26 (100%)
Imaging +
Total
13/16 (81%)
With 1other sign (except back pain)
HLAB27
11/16
9/11
HLAB27+
16/24 (67%)
With 2 other signs
5/16

9. Résults (3) Criterias of severity BASDAI >4 BASFI > 4
Obvious severe symptoms
1 uveitis
≥ 3 simultaneous inflammed joins
3/26
≠ 2 occasions
BASDAI >4
12/17 (71%)
BASFI > 4
13/17 (76%)
BASFI > 4 +BASDAI > 4
10/17
Continuous and maximal dose NSAI
Untapped
Unconformity between interrogatory and databases

10. DISCUSSION Some diagnostic doubts Subjectivity burden
Compliance with the treatment algorithm?

11. Diagnostic doubts Inflammatory character of back pain?
Limits of imaging  :
MRI – : 3 /16 : operator-dependant?
Association with HLAB27 : 9/16
HLAB27 : always a major diagnostic criteria

12. Criteria of severity: too much place for subjectivity
Treatment with NSAI
Difficult analysis
Safety?
Shortage of objectives signs (3/26)
Burden of the clinical disease indices

13. Compliance with treatment algorithm?
NSAI
>3 months: rarely
Bad safety
Poverty of therapeutic resources
Quick start for anti-TNF
5/11 cases with biotherapy ongoing at the time of application

14. CONCLUSION Difficult diagnosis
Important part of the borderline cases (¼)
Overestimation by imaging with major impact on diagnosis
Rigourous lack in characterization of each sign
→ Request the prior consent for starting anti-TNF treatment ?
article L315-2 du CSS
Innovativeness
Risk exposure
Onerous character

15. Thank you..