1. Managing your Inflammatory Back Pain Dr Amanda Isdale Rheumatologist York Teaching Hospital

2. Inflammatory Back Pain Presenting symptom of the Axial Spondyloarthropathy spectrum of diseases Chronic- more than 3/12 Gradual onset before age 45 years Relieved by exercise, no improvement with rest Relieved by NSAIDs

3. Estimated proportion of affected individuals* Time Spectrum of Axial Spondyloarthritis Axial SpA (ASAS criteria) Ankylosing Spondylitis (modified New York criteria) Patients with chronic back pain ≥3 months and aged <45 years Non-radiographic stage X-ray-negative MRI positive sacroiliitis MRI negative, HLA-B27-positive** Radiographic stage X-ray-positive sacroiliitis Radiographic stage X-ray-positive sacroiliitis and/or spinal changes*** * Heights reflect an estimate of the proportion of patients in each group ** Clinical arm if non-radiographic axial SpA *** Radiographic evidence if inflammatory spinal changes including i.e., syndesmophytes, fusion or posterior element involvement

4. Delays in diagnosis 15% of UK primary care population meet criteria for IBP Mean delay in diagnosis 8.57 years WHY? Patients not bothering to see GP- see other AHPs Failure to recognise symptoms Failure to image appropriately Belief that can be managed in primary care (35% of GPs)

6. But many common needs Getting the right diagnosis! Mechanical vs inflammatory vs other conditions; Non- radiographic axial SpA vs AS Seeing a specialist team Getting the right information Understanding the diagnosis Accepting the diagnosis Taking ownership

7. Management needs to tailored to an individual Dependent on: Stage of disease Severity of disease Activity of the disease General health of the patient Presence of other medical conditions Response and tolerance of pharmaceutical interventions

8. You have Axial SpA/AS Active vs passive acceptance Positive vs negative attitude Understanding your condition- reading the recommended PILs etc Seeking help when needed Accepting medication may be necessary Helping yourself

9. Lifestyle changes Stop smoking- known to result in poorer outcome and adverse effects on general health Lose weight if necessary aiming for healthy weight for height Avoid a sedentary lifestyle Listen to and follow the advice of your specialist team- particularly the physio Adjust work, hobbies and sport if required Invest in a good bed

10. The potential legacy of the disease without effective treatment

11. What happens to the spine in AS? The spine is like a suspension bridge It flexes and extends and is able to transmit and distribute force Remember Newton’s cradle with the 5 hanging balls? If it can’t move, it can’t transmit and distribute force

14. Getting the foundation right: Early disease Specialist Physiotherapy- exercise & stretching. Group sessions are better than individual: NASS classes, hydro sessions, Pilates classes, aqua- aerobics etc Adequate pain and anti-inflammatory relief to engage in the physio programme May require IM steroid to reduce inflammation or sometimes injection of steroid to the sacroiliac joints Managing fatigue

15. Established Spinal Disease: AS Physio exercises & stretching NSAIDs & analgesics Using IM steroid for flares Assessing for osteoporosis Identifying fracture vs flare Managing eg hip disease with replacement

17. Other non-spinal considerations Peripheral joints & entheses Eye disease: uveitis- can occur at any time, usually 1 eye at a time; generally better on anti-TNF Gut disease: NSAID related; Inflammatory bowel disease- may present insidiously Skin: psoriasis Cardiovascular: heart valve disease; arrhythmias etc

18. Management Spine: Failure of Standard Interventions If there is poor response to these interventions; assess for biologic agents Anti-TNF( Etanercept, Adalimumab, Golimumab, Certolizumab) Require measures of active disease (BASDAI & pain >4) on 2 occasions 3/12 apart + use of 2 full strength NSAIDs +other non AxSpA criteria for use

19. To ponder Anti-TNF:effective disease modifying but not curative therapies New biologics on stream targetting different pathways Biosimilars- cheaper (slightly), ?similar Remission? Early treatment better outcomes. When to reduce/stop? What can we afford in the future? Not everyone needs anti-TNF- getting the right balance but not missing the boat

20. Summary Early diagnosis is essential Self management & taking ownership of your condition are of paramount importance Exercise, stretching & lifestyle adjustments are still the foundation stones Biologic drug treatment has been a major advance but are not a cure & they can have limitations