HLA-B27 +/LBP/Normal Imaging

[101N]

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Only 26% progress to AS. Holster your opioids...


Arthritis Rheumatol. 2015 Dec 14. doi: 10.1002/art.39542. [Epub ahead of print]
Progression of Patients with Non-Radiographic Axial Spondyloarthritis to Ankylosing Spondylitis: A Population-Based Cohort Study.
Wang R1, Gabriel SE2,3, Ward MM1.
Author information

Abstract
OBJECTIVE:
The long-term outcome of patients with non-radiographic axial spondyloarthritis (nr-axSpA) is unclear, particularly whether few or most progress to ankylosing spondylitis (AS). Our objective was to examine the progression to AS in a population-based inception cohort of patients with nr-axSpA.

METHODS:
The Rochester Epidemiology Project (REP) is a longstanding population-based study of health in the residents of Olmsted County, Minnesota. We searched the REP from 1985 to 2010 using diagnostic and procedural codes for back pain, HLA-B27 and pelvis magnetic resonance imaging, and performed detailed chart review to identify subjects who fulfilled the Assessment of Spondyloarthritis International Society classification criteria for axSpA but did not have AS. We followed these subjects from disease onset to March 15th , 2015, and used survival analysis to measure time to progression to AS.

RESULTS:
After screening 2151 patients, we identified 83 subjects with new-onset nr-axSpA. Over a mean follow-up of 10.6 years, 16 subjects progressed to AS. The probabilities of remaining as nr-axSpA at 5, 10, and 15 years were 93.6%, 82.7%, and 73.6%, respectively. Subjects in the imaging arm (n=18) progressed more frequently and rapidly than those in the clinical arm (n=65) (28% versus 17%; hazard ratio 3.50, 95% CI 1.15-10.6, p=0.02).

CONCLUSIONS:
A minority (26%) of patients with nr-axSpA progressed to AS when followed for up to 15 years. This suggests that the classification criteria for nr-axSpA identifies many patients unlikely to progress to AS, or that nr-axSpA is a prolonged prodromal state, requiring longer follow-up to evolve to AS. This article is protected by copyright. All rights reserved.

© 2015, American College of Rheumatology.

 

[lobelsteve]

non-radiographic axial spondyloarthritis does not compute. To me this means CLBP and is not a diagnosis.
Holster opiates and needles. Try Humira, it's delightful.

 

[101N]

http://www.medscape.org/viewarticle/849725

 

[lobelsteve]

http://www.medscape.org/viewarticle/849725

Yup, Rheums being Rheumie.
GIGO powerpoint for this. Basically says if HLA+ and Xray neg get an MRI. Response to NSAID was noted. But this does not mean any procedure or narcotic is indicated, only that biologics may benefit.

 

[101N]

Agree. But the trick is picking out - before there is radiographic disease - the 26% that may go on to AS and thus benefit from prophylactic biologics.

 

[Jcm800]

non-radiographic axial spondyloarthritis does not compute. To me this means CLBP and is not a diagnosis.
Holster opiates and needles. Try Humira, it's delightful.

My thoughts exactly. No x ray findings, but yet spondyloarthritis? How do we know it's spondyloarthritis if the xray doesn't show it?

 

[SSdoc33]

Agree. But the trick is picking out - before there is radiographic disease - the 26% that may go on to AS and thus benefit from prophylactic biologics.

prophylactic 20k/year injection medications with craploads of side effects? i wouldnt want to develop AS either, but......

 

[101N]

And how effective is it at prophylaxis?

 

[clubdeac]

Any time I send a patient to the rheum that is a young male with SIJ pain and +HLA-B27, he dismisses it and sends me a nice educational assessment back stating something to the fact that 10-20% of the white population has a false positive lab finding. He then goes on to note no evidence of uveitis, enthesopathy or other signs of inflammation. Ughhhh

 

[Dr. Ice]

I don't get rheumatologists. I will often times
start a workup for them and sometimes positive Ana rf anti ccp esr crp will come back and I would think it would be a nice present for them to at least follow and they will invariably send it back saying the patient has fibro. What exactly do they want to treat? Baffles me..

 

[melancholy]

I don't get rheumatologists. I will often times
start a workup for them and sometimes positive Ana rf anti ccp esr crp will come back and I would think it would be a nice present for them to at least follow and they will invariably send it back saying the patient has fibro. What exactly do they want to treat? Baffles me..

yeah that doesnt' make sense, but there are enough patients out there that do have a confirmable autoimmune process + fibromyalgia concomitantly which makes it challenging to stabilize them at times when their autoimmune disease is acting up or vice versa.

 

[Dr. Ice]

yeah that doesnt' make sense, but there are enough patients out there that do have a confirmable autoimmune process + fibromyalgia concomitantly which makes it challenging to stabilize them at times when their autoimmune disease is acting up or vice versa.

Yeah that may be true but why not give the option to try a biologic? Hell put em on steroids or Celebrex or something. This makes it seem like they don't care and don't have any interest in receiving referrals.

 

[melancholy]

Yeah that may be true but why not give the option to try a biologic? Hell put em on steroids or Celebrex or something. This makes it seem like they don't care and don't have any interest in receiving referrals.

true, i do feel the same way when i do the workup and package it up nicely, then find out they don't want to do anything and say it is more fibro or psych issues than anything else. ugh.

 

[101N]

We don't do this for referrals, I hope. As long as that mindset persists we will never be offering best care.

 

[Disciple]

It's the same reason the pain doctor doesn't want to treat non-specific mid-back pain with equivocal imaging, or the orthopod doesn't want to treat hip pain that doesn't require a hip replacement.

You could insert any specialty here.

I'd say it's the norm, rather than the exception.

 

[Dr. Ice]

It's the same reason the pain doctor doesn't want to treat non-specific mid-back pain with equivocal imaging, or the orthopod doesn't want to treat hip pain that doesn't require a hip replacement.

You could insert any specialty here.

I'd say it's the norm, rather than the exception.

True..we all see things that we don't necessarily want to see but we don't all send these patients back and say not my problem yet. What kind of medical community would that be? Give some clinical feedback, educate, offer a follow up appointment if still symptomatic despite other failed intervention. At least that's what I try to do with things I don't want to see..like scoliosis and thoracalgia.

 

[Tenesma]

so we know there is a delay in adolescents between suspicion for AS and actual radiographic AS --- however, i have seen patients dx w/ AS by Rheum - and have seen xrays spanning 1-2-3 decades without radiographic evidence of AS... whazup w that?