1. Welcome to SpA SIG August 2, 2006 MR 304 : 15.30-16.30

2. How you diagnose and assess disease activity in AS: Results of a questionnaire study Ratanavadee Nanagara, M.D. Allergy-Immunology-Rheumatology Unit KhonKaen University Thailand

3. parameters being used in common practice for diagnosis and assessment of AS patients. parameters being used in common practice for diagnosis and assessment of AS patients. comments, suggestion, and revised by experience AS researchers 80 parameters for AS diagnosis, 32 for AS assessment electronically distributed Questionnaire

4. to assess the degree of importance of …parameters used for diagnosis and assessment of AS patients … *** rheumatologist running clinical practice for at least 5-10 years ….. up to the individual opinion.. used in clinical practice, not in research…. * each item was scored as 1 or 2 or 3. 1 = not important 2 = moderate important 3 = extremely important Purpose “The must”

7. Australia (1) Lionel Schachna Hongkong (4)Isaac YIM, Cheuk-wan Lai Shan Tam Lau Chak Sing Lee Ka Wing India (4)Ashok Kumar Rohini Handa Ved Chaturvedi Vikas Agarwal Indonesia (1)John Darmawan Korea (3)Sang-Hoon, Lee. Tae-Hwan Kim Tae Jong Kim Malaysia (4)Gun Suk Chyn Lew LWG Swan Sim Yeap Swee Gaik Ong Philippines (4)Evelyn Salido Juan Javier Lichauco Julie Li Yu Sandra V. Navarra Singapore (5)Anita Lim Chew Li-Ching Julian Thumboo Kok Ooi Kong Spore Bernard Thong Taiwan (1)Chung-Tei Chou Thailand (4)Boonjing Siripaitoon Ratanavadee Nanagara Sittichai Ukritchon Worawit Laoraenu 31 responders from 10 APLAR countries 31 responders from 10 APLAR countries Results analysis

8. > 80% of responders scored as important ( 2 + 3) Parameter for diagnosis including: CRP, ESR, most plain films, and MRI 70% agree with B-27 study, less with RF including: CRP, ESR, most plain films, and MRI 70% agree with B-27 study, less with RF Parameter for assessment Including: VAS, BASFI, BASDAI, GA, +BASMI 43 / 57 clinical parts 29 / 32 items listed 9 / 23 Lab. tests

9. > 80% of responders scored as “The Must” (3) 43  3 / 57 clinical parts Parameter for diagnosis film pelvis 9  1 / 23 Lab. tests Schober test Inflammatory back pain, morning pain, Schober test Inflammatory back pain, morning pain, Schober test Parameter for assessment 29  1 / 32 items listed

10. > 60% of responders scored as “The Must” (3) 43  3  10 / 57 clinical parts Parameter for diagnosis film pelvis 9  1  1 / 23 Lab. tests Schober, morning pain peripheral joints & eye exam, VAS (pain, global), BASDAI, Schober, morning pain peripheral joints & eye exam, VAS (pain, global), BASDAI, back pain characteristics eye sign, sausage digits chest expansion back pain characteristics eye sign, sausage digits chest expansion Parameter for assessment 29  1  6 / 32 items listed 50-60 % scored for chest expansion, enthesitis BASFI, CRP, ESR 50-60 % scored for chest expansion, enthesitis BASFI, CRP, ESR 50% scored for MRI, 30% scored for B-27

11. Conclusion (1) 1.Majority of the responders agree that most parameters used for diagnosis and assessment of AS patients are important. 2. However, limited numbers of these parameters have been using in their clinical practice. 3. At least, characteristics of back pain, Schober test, chest and eye exam, and film pelvis were evaluated by 80% of the responders.

12. 4. About half used MRI of SI joint for AS diagnosis, while one third need genetic study. 5. Half of the responders used AS measurement parameters (BASDAI, BASFI, VAS) and inflammatory parameters (CRP, ESR) during AS assessment for their optimal care. Conclusion (2)

14. 15:30-15:42 How APLAR countries can contribute to international research David YUUSA 15:42-15:54 How you diagnose and assess disease activity in AS, results of a questionnaire study Ratanavadee NanagaraThailand 15:54-16:06 Are UspA and AS 2 different diseases? Result from cohort study Chung-Tei ChouTaiwan 16:06-16:18 Towards a perfect epidemiological Study of SpA, experience in China Swee Cheng Ng Singapore 16:18-16:30 Do UspA patients respond to TNF blockers Jieruo Gu China

16. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % History not imp. must Gender 25.845.229.074.2 Age 9.751.638.790.3 Ethnicity 58.122.619.441.9 Family history of SpA 3.241.954.896.8 Family history of psoriasis or IBD or iritis 6.551.641.993.5 History of HLA-B27 in family members 19.458.122.680.6 Age of onset of symptoms of AS 3.248.445.293.5 > 50% used in clinical practice

17. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % History notimp. must History of preceding diarrhea or genital discharge or balanitis 12.951.635.587.1 History of preceding injury 71.022.66.529.0 History of psoriasis 6.548.445.293.5 History of IBD 0.054.845.2100.0 History of iritis 0.032.367.7100.0 History of buttock pain 0.025.874.2100.0 Whether buttock pain is alternating 32.3 35.567.7 Whether patient is waken up by night pain 9.719.471.090.3 > 50% used in clinical practice > 70%

18. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % History not imp. must History of cervical spinal pain 22.635.541.977.4 History of thoracic spinal pain 22.635.541.977.4 History of lumbar spinal pain 6.535.558.193.5 Whether spinal pain is "inflammatory" by Calin definition 0.06.593.5100.0 Age of onset of spinal pain before age 40 3.225.871.096.8 Whether onset of spinal pain is insidious 12.951.635.587.1 Duration of spinal pain if it is more than 3 months 9.732.358.190.3 > 50% used in clinical practice > 70%

19. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % History notimp. must Whether spinal pain is improved by exercise 3.225.871.096.8 Whether there is morning stiffness of spine 3.29.787.196.8 Whether spinal pain is improved by rest 25.8 48.474.2 Whether spinal pain is relieved by NSAIDs 19.441.938.780.6 Presence of peripheral joint pain 6.548.445.293.5 Presence of peripheral joint stiffness 9.754.835.590.3 Whether peripheral joint pain is oligo in number, asymmetrical and predominantly in lower extremities 6.545.248.493.5 > 50% used in clinical practice > 70%

20. Parameters used in diagnosis of ASS1%S2%S3% 2+3 % History not Imp. must Presence of pain in shoulders 22.658.116.174.2 Presence of pain in hips 3.248.4 96.8 Presence of pain at heels 6.541.951.693.5 History of sausage digits 6.532.361.393.5 Presence of rib cage and anterior chest wall pain 19.445.235.580.6 History of skin rash on any parts of the body 22.651.625.877.4 History of HLA-B27 blood test in patient 22.648.429.077.4 > 50% used in clinical practice

21. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % Physical examination not Imp. must Gait 19.448.416.164.5 Presence of abnormal posture 9.748.441.990.3 Occiput to wall distance 9.745.2 90.3 Tragus to wall distance 12.948.438.787.1 Degree of cervical rotation 6.551.641.993.5 Degree of cervical lateral rotation 12.951.635.587.1 Schober test for forward flexion of lumbar spine 0.09.787.196.8 Lateral flexion of lumbar spine 16.141.9 83.9 Finger to floor distance 25.848.425.874.2 > 50% used in clinical practice > 70%

22. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % Physical examination not Imp. must Intermalleolar distance 35.548.416.164.5 Measurement of chest expansion 6.529.064.593.5 Presence of sausage digits 9.732.358.190.3 Swelling of peripheral joints 3.248.4 96.8 Tenderness of peripheral joints 6.558.135.593.5 Swelling of heels 12.929.058.187.1 Tenderness of heels 6.545.248.493.5 > 50% used in clinical practice

23. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % Physical examination not Imp. must Range of motion of shoulders and hips 6.551.641.993.5 Physical exam for active sacroiliitis e.g. Patrick test 9.741.948.490.3 Physical exam for skin abnormalities 16.148.435.583.9 Physical exam for redness or swelling of eyes 6.548.445.293.5 Auscultation for aortic insufficiency 41.932.325.858.1

24. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % Laboratory diagnosis not Imp. must 0.0 WBC 71.016.19.725.8 Differential wbc count 77.416.16.522.6 Hgb 45.238.716.154.8 Platelet count 45.235.519.454.8 Urine analysis 54.825.819.445.2 Standard blood chemistry 61.322.616.138.7

25. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % Genetic & Serologic tests not Imp. must 3.2 HLA-B2725.841.929.071.0 Rheumatoid factor64.522.612.935.5 ANA77.412.99.722.6 ESR3.241.954.896.8 CRP3.245.248.493.5 > 50% used in clinical practice

26. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % Radiographic evaluation not Imp. must X-ray of pelvis for sacroiliitis0.06.593.5100.0 Scoring of the degree of sacroiliitis12.935.551.687.1 CT of sacroiliac joints25.838.735.574.2 MRI of sacroiliac joints16.132.351.683.9 MRI of spine35.545.219.464.5 X-ray of hips12.954.832.387.1 > 50% used in clinical practice > 70%

27. Parameters used in diagnosis of AS S1 % S2 % S3 % 2+3 % Radiographic evaluation not Imp. must 0.0 Bone scan 41.945.212.958.1 X-ray of spine: cervical 19.451.629.080.6 X-ray of spine: thoracic 16.158.125.883.9 X-ray of spine: lumbar 9.738.751.690.3 Ultrasound 80.69.7 19.4 Bone density assessment 48.435.59.745.2 > 50% used in clinical practice

28. Parameters used in assessment of AS S1 % S2 % S3 % 2+3 % Occupation 19.438.741.980.6 Whether occupation if physically demanding 12.945.241.987.1 Whether the patient has to take sick leave for his arthritis 9.751.638.790.3 Patient global assessment VAS 3.229.067.796.8 Degree of fatigue 19.451.629.080.6 BASDAI score 12.922.664.587.1 > 50% used in clinical practice

29. Parameters used in assessment of AS S1 % S2 % S3 % 2+3 % Degree of peripheral joint pain in a VAS scale 22.635.541.977.4 Degree of spinal pain in a VAS scale 12.922.664.587.1 Degree of morning stiffness in a VAS scale 6.535.558.193.5 Duration of morning stiffness 6.516.177.493.5 BASFI score or other functional scoring systems 9.735.554.890.3 Other health questionnaires 29.051.616.167.7 Physician global assessment on a scale of 0-4 or 0-10 16.151.632.383.9 > 50% used in clinical practice > 70%

30. Parameters used in assessment of AS S1 % S2 % S3 % 2+3 % Occiput to wall distance 3.258.138.796.8 Tragus to wall distance 12.941.945.287.1 Degree of cervical rotation 6.551.641.993.5 Degree of cervical lateral rotation 12.958.129.087.1 Schober test for forward flexion of lumbar spine 3.212.983.996.8 Lateral flexion of lumbar spine 12.951.635.587.1 Finger to floor distance 9.761.329.090.3 Intermalleolar distance 25.851.622.674.2 Measurement of chest expansion 6.535.558.193.5 > 50% used in clinical practice > 70%

31. Parameters used in assessment of AS S1 % S2 % S3 % 2+3 % Presence of sausage digits 6.538.754.893.5 Swelling of peripheral joints 0.029.071.0100.0 Tenderness of peripheral joints 0.058.141.9100.0 Swelling of heels 12.935.551.687.1 Tenderness of heels 9.754.835.590.3 Range of motion of shoulders and hips 3.245.251.696.8 Physical exam for active sacroiliitis e.g. Patrick test 12.935.551.687.1 Physical exam for redness or swelling of eyes 0.038.761.3100.0 ESR 0.041.958.1100.0 CRP 0.045.254.8100.0 > 50% used in clinical practice > 70%