Spondyloarthritis (or spondyloarthropathy) is the name for a family of inflammatory rheumatic diseases that cause arthritis. The most common is ankylosing spondylitis, which affects mainly the spine. Others include:
- axial spondyloarthritis, which affects mainly the spine and pelvic joints;
- peripheral spondyloarthritis, affecting mostly the arms and legs;
- reactive arthritis (formerly known as Reiter’s syndrome);
- psoriatic arthritis; and
- enteropathic arthritis/spondylitis associated with inflammatory bowel diseases (ulcerative colitis and Crohn’s disease).
What you need to know about Spondyloarthritides
Spondyloarthritides are a group of arthritic diseases that share several common features. They can cause inflammation of the spine; however, other joints may be affected.
The tendon and ligament tissue near the spine or joint is also involved. A high percentage of people with these diseases share a similar gene called HLA B27.
Finally, many patients also have inflamed areas in the eye, bowel, genital tract or skin.
The spondyloarthropathies include:
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis/Reiter’s syndrome
- Enteropathic arthritis
Undifferentiated: Patients with features of more than one disease who do not fit in the defined categories above
Ankylosing spondylitis (AS)
AS is a chronic, systemic, inflammatory disease of the joints and ligaments of the spine. Other joints may be involved. This typically results in pain and stiffness in the spine.
The disease may be mild to severe. The bones of the spine may fuse over time causing a rigid spine.
Early diagnosis and treatment may help control the symptoms and reduce debility and deformity.
Who gets ankylosing spondylitis (AS)?
The onset is typically in late adolescence to early adulthood. It is rare for AS to begin after age 45. The disease is more common in men and in Caucasians.
The incidence is 1 in 1000 persons. About 90% of people with AS have the HLA B27 gene.
What causes ankylosing spondylitis (AS)?
The cause of AS is unknown although there appears to be some genetic component. AS is associated with the HLA B27 gene but it is unclear why.
The gene is seen in about 8% of normal Caucasians. There are no known infectious or environmental causes.
What are the signs and symptoms?
Early on, there is pain and stiffness in the buttocks and low back due to sacroiliac joint involvement. Over time, the symptoms can progress up the spine to involve the low back, chest and neck.
Ultimately, the bones may fuse together causing limited range of motion of the spine and limiting one’s mobility. Shoulders, hips and sometimes other joints may be involved.
AS may affect tendons and ligaments. For example, the heel may be involved with Achilles tendonitis and plantar fasciitis.
Since it is a systemic disease, patients can get fever and fatigue, eye or bowel inflammation, and rarely, there can be heart or lung involvement.
AS is typically non life-threatening. Usually, it is a slowly progressive disease. Most people are able to work and function normally.
How is Spondyloarthritis diagnosed?
Correct diagnosis requires a physician to assess the patient’s medical history and do a physical exam. The doctor also may order imaging tests or blood tests.
You may need an X-ray of the sacroiliac joints, a pair of joints in the pelvis. X-ray changes of the sacroiliac joints, known as sacroiliitis, are a key sign of spondyloarthritis.
If X-rays do not show enough changes, but the symptoms are highly suspicious, your doctor might order magnetic resonance imaging, or MRI, which shows these joints better and can pick up early involvement before an X-ray can.
Among the blood tests you may need is a test for the HLA-B27 gene. However, having this gene does not mean spondyloarthritis will always develop.
Some people have the HLA-B27 gene but do not have arthritis and never develop arthritis. In the end, the diagnosis relies on the doctor’s judgment.
How is Spondyloarthritis treated?
All patients should get physical therapy and do joint-directed exercises. Most recommended are exercises that promote spinal extension and mobility.
There are many drug treatment options. The first lines of treatment are the NSAIDs, such as naproxen, ibuprofen, meloxicam or indomethacin.
No one NSAID is superior to another. Given in the correct dose and duration, these drugs give great relief for most patients.
For joint swelling that is localized (not widespread), injections, or shots, of corticosteroid medications into joints or tendon sheaths (the membrane around a tendon) can be effective quickly.
For patients who do not respond to the above lines of treatment, disease modifying antirheumatic drugs (commonly called DMARDs) such as sulfasalazine (Azulfidine) might be effective.
These drugs relieve symptoms and may prevent damage to the joints. This class of drugs is helpful mainly in those with arthritis that also affects the joints of the arms and legs.
Although they may be effective, corticosteroids taken by mouth are not advised. This is because the high dose required will lead to many side effects.
Antibiotics are an option only for patients with reactive arthritis.
TNF alpha blockers (a newer class of drugs known as biologics) are very effective in treating both the spinal and peripheral joint symptoms of spondyloarthritis.
TNF alpha blockers that the FDA has approved for use in patients with ankylosing spondylitis are:
- infliximab (Remicade), which is given intravenously (by IV infusion) every 6-8 weeks at a dose of 5 mg/kg;
- etanercept (Enbrel), given by an injection of 50 mg under the skin once weekly;
- adalimumab (Humira), injected at a dose of 40 mg every other week under the skin; and
- golimumab (Simponi), injected at a dose of 50 mg once a month under the skin.
However, anti‐TNF treatment is expensive and not without side effects, including an increased risk for serious infections.
Biologics can cause patients with latent tuberculosis (no symptoms) to develop active infection with TB. Therefore, you and your doctor should weigh the benefits and risks when considering treatment with biologics.
Those with arthritis in the knees, ankles, elbows, wrists, hands and feet should try DMARD therapy before anti-TNF treatment.
Surgical treatment is very helpful in some patients. Total hip replacement is very useful for those with hip pain and disability due to joint destruction from cartilage loss.
Spinal surgery is rarely necessary, except for those with traumatic fractures (broken bones due to injury) or to correct excess flexion deformities of the neck, where the patient cannot straighten the neck.
Reactive arthritis (ReA)
Reactive arthritis is a non-infectious inflammation of one or several joints. It may be self-limited, relapsing or chronic.
The condition sometimes follows an infection of the gastrointestinal or genitourinary system. There may be other non-joint features such as eye, genital tract, bowel or skin inflammation.
The term Reiter’s Syndrome is an older term that most rheumatologists have now replaced with Reactive Arthritis.
Reiter’s Syndrome was a term originally used to refer to a syndrome of non-infectious eye, genital and joint inflammation following a previous bowel or genital bacterial infection. All of these features are rarely seen together.
Who gets reactive arthritis?
ReA may follow an infection of the genital tract or bowel, but this is not always identified. It is more common in men and Caucasians. ReA is rare after the age of 50. The disease is associated with the HLA B27 gene in 50 – 80% of patients.
What causes reactive arthritis?
The cause of ReA is unknown. It is associated with the HLA B27 gene, but it is unclear why. It is also unclear why ReA is sometimes associated with infection.
(Bacterial infections of genital tract with Chlamydia or gastrointestinal tract with Shigella, Salmonella, or Campylobacter).
What are the signs and symptoms of reactive arthritis?
ReA may follow several weeks after a genital tract or bowel infection. The patient may have acute swelling, pain and redness in one or more joints.
Typically, it is more common in the lower extremity joints. During the joint symptoms, one may also have non-infectious genital tract, skin or eye inflammation.
ReA patients may have tendonitis, especially of the heel. There may be spine involvement (like ankylosing spondylitis).
Traditionally, ReA is self-limited to 3 to 12 months, but up to 50% may have relapsing or chronic disease. The disease is not life threatening, and most people are able to work and function normally.
How is reactive arthritis diagnosed?
The diagnosis is typically made by a doctor taking a thorough history and physical examination. A swollen joint may be aspirated to rule out an infection or gout.
There is no specific test for the diagnosis of ReA. The HLA B27 gene may be checked by blood test in selected cases, but it is not diagnostic.
How is reactive arthritis treated?
At this time, there is no curative treatment. Any existing infection, if discovered, should be treated. The role of routine antibiotics is controversial.
Physical therapy, stretching and exercise are prescribed. Non-steroidal anti-inflammatory drugs (NSAIDs) are given for pain and stiffness.
Steroid injections to involved tendons or joints can help relieve pain and inflammation.
In chronic or relapsing cases, similar treatments to rheumatoid arthritis can be considered to include methotrexate, sulfasalazine and the biologic anti-TNF-a drugs (as listed for AS).
Enteropathic arthritis is peripheral joint or spine disease associated with inflammatory bowel disease (IBD), such as Crohn’s Disease or Ulcerative Colitis.
Who gets enteropathic arthritis?
Enteropathic arthritis is seen in up to 10 – 20% of those with IBD. It is more common in juveniles and young adults. The male to female ratio is equal.
What causes enteropathic arthritis?
The cause is unknown.
What are the signs and symptoms of enteropathic arthritis?
The arthritis typically occurs after the bowel disease is well established. Rarely, the arthritis can start before IBD is diagnosed.
There is pain and swelling in one or more joints. Typically, the arthritis occurs in the lower extremity joints. The arthritis may mirror the activity of the bowel disease.
There may also be spine involvement (like ankylosing spondylitis). The HLA B27 gene is seen in up to 50% with spine involvement. The spondylitis (spine involvement) is less likely to correlate with the bowel disease activity.
Patients may have other systemic symptoms such as fever, skin or eye inflammation, and oral ulcers. Enteropathic arthritis rarely causes joint destruction, deformity or significant disability.
How is enteropathic arthritis treated?
Like the other spondyloarthropathies, the patient needs physical therapy and exercise. Treatment of the bowel disease may help the peripheral joints but not the spine.
Removing the colon (colectomy) in ulcerative colitis may “cure” the arthritis.
One can use non-steroidal anti-inflammatory drugs (NSAIDs), but there is a need to be aware of the bowel effects. Local injection of steroids into joint(s) can be very helpful. Oral steroids can be used in more severe cases.
In resistant cases, medications normally used to treat rheumatoid arthritis, such as methotrexate, azathioprine (Imuran®) or sulfasalazine can be tried for the joints.
Anti-TNF-a drugs, like adalimumab (Humira®) and infliximab (Remicade®) have shown benefit with joint and bowel disease.