Arthritis associated with HLA-B27
Indeed, spondylartritis can be ankylosing spondylitis (AS), psoriatic arthritis or enterocolopathies, reactive arthritis, SAPHO, undifferentiated AS. They all have in common to have HLA B27 + in 50 to 90% of cases.
Pharmacologically, non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment. Analgesics may be combined with NSAIDs if they are not effective enough to completely eliminate the pain, or replace them if there is a contraindication. As a second-line treatment, salazopyrin or methotrexate for a long time have been proposed for lack of anything better: they are not very effective in most cases. Intra-articular injections of corticosteroids may be considered to relieve inflammation of certain painful joints.
When none of these conventional treatments is sufficient to stop the activity of the disease, more powerful treatments by biotherapies are envisaged. These drugs target effectors of inflammation. Several anti-TNF (anti-TNF drug) molecules block the action of TNF-alpha, a protein responsible for tissue inflammation. Injectables are indicated today in the treatment of spondyloarthritis: infliximab, adalimumab, etanercept, golimumab, certolizumab. They all block the same target: TNF alpha, one of the key proteins of inflammation. However, 30% of patients do not respond correctly to these drugs; in others, their effectiveness gradually decreases. Therapeutic research is continuing to propose new therapeutic options. Thus, ustekinumab, which targets other mediators of inflammation (IL-12 / IL-23), is now prescribed in forms associated with psoriasis. Secukinumab (anti-IL17) and apremilast (anti-PDE4) are the most advanced drugs, followed by molecules targeting the JAK kinaseskinases pathway (tofacitinib, baricitinib ...).
The search for new clinical or biological markers to predict the onset of spondyloarthritis, its risk of progression, severity, or its response to treatment has developed in recent years.
Thus, the identification of genetic risk factors explaining the occurrence of the disease should facilitate the diagnosis of the disease. Others may help predict the course of the disease and adapt the treatment accordingly.
Research is conducted to identify biological markers of the evolution of the disease: anti-CD27, MMP-3 antibodies ...
Finally, studies are conducted to predict or monitor the effectiveness of treatments: they are particularly interested in pharmacogenetics and the search for anti-drugs.
These are diseases of the digestive tract (inflammatory enthérocolopathies) that can be associated with articular lesions such as spondylarthritis (SAI) with oligo or mono arthritis and involvement of entheses.
The search for bloody diarrhea must therefore be systematic during the interrogation; Digestive diagnosis requires colonoscopy. Management must take into account both diseases.
5- Rheumatism of palmoplantar pustulosis and SAPHO (Synovitis, Acne, Pustulose, Hyperostosis, Osteitis)
They are close to psoriatic arthritis but much rarer.
Ankylosing spondylitis
Symptoms
Ankylosing spondylitis (AS) preferentially affects the young man with lumbar spine and sacroiliac (buttocks pain) according to an inflammatory schedule (source of nocturnal awakenings and a morning stiffness of more than 20 min). Sometimes associated with a impairment of the joints of the limbs: knees, ankles, hands or feet especially heels (talalgia) more rarely the ends of the fingers and toes that can become red, swollen like a small "sausage". Often these pains are very sensitive to nonsteroidal anti-inflammatory drugs (NSAIDs). Sometimes an eye problem (uveitis) can be associated.
Diagnosis
In blood tests, the inflammatory syndrome is variable (C-reactive protein (CRP) and sedimentation rate are normal in more than half of cases), we can often highlight (80% of cases) a gene called HLA B27 but the AS is not a genetic disease (this gene is normal and remains very common in non-sick subjects, moreover it is not found in some AS !!!)
X-rays are very often normal at the beginning of the disease and it takes several years to see images of sacroiliitis (on the pelvis), syndesmophytes (on the rachis) or calcaneal spines (on the heel).
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| Bilateral sacroiliitis (Arrow) associated to an AS |
The mechanical "back pain" is very common in our populations and the blood tests and X-rays are usually normal at the beginning, we understand that the diagnosis can be difficult and long (on average 8 to 9 years!); but knowledge about the disease is changing and this time is shortened especially through the use of MRI.
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| MRI of Ankylosing Spondylitis |
Evolution
The evolution of this rheumatism is capricious, it is done by successive pushes between which the patient does not feel anything at the beginning then the crises can get closer and the pain becomes permanent. The evolutionary risk is ankylosis, that is to say the ossification of the articular damage that binds the bone parts resulting in a progressive loss of mobility source of increasing functional gene.
Treatment
The care must be multidisciplinary (attending physician, rheumatologist, physiotherapists ...) and adapted to each patient. The objectives are to calm the pain and the inflammation, and to fight against a possible stiffness.
Pharmacologically, non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment. Analgesics may be combined with NSAIDs if they are not effective enough to completely eliminate the pain, or replace them if there is a contraindication. As a second-line treatment, salazopyrin or methotrexate for a long time have been proposed for lack of anything better: they are not very effective in most cases. Intra-articular injections of corticosteroids may be considered to relieve inflammation of certain painful joints.
When none of these conventional treatments is sufficient to stop the activity of the disease, more powerful treatments by biotherapies are envisaged. These drugs target effectors of inflammation. Several anti-TNF (anti-TNF drug) molecules block the action of TNF-alpha, a protein responsible for tissue inflammation. Injectables are indicated today in the treatment of spondyloarthritis: infliximab, adalimumab, etanercept, golimumab, certolizumab. They all block the same target: TNF alpha, one of the key proteins of inflammation. However, 30% of patients do not respond correctly to these drugs; in others, their effectiveness gradually decreases. Therapeutic research is continuing to propose new therapeutic options. Thus, ustekinumab, which targets other mediators of inflammation (IL-12 / IL-23), is now prescribed in forms associated with psoriasis. Secukinumab (anti-IL17) and apremilast (anti-PDE4) are the most advanced drugs, followed by molecules targeting the JAK kinaseskinases pathway (tofacitinib, baricitinib ...).
The search for new clinical or biological markers to predict the onset of spondyloarthritis, its risk of progression, severity, or its response to treatment has developed in recent years.
Thus, the identification of genetic risk factors explaining the occurrence of the disease should facilitate the diagnosis of the disease. Others may help predict the course of the disease and adapt the treatment accordingly.
Research is conducted to identify biological markers of the evolution of the disease: anti-CD27, MMP-3 antibodies ...
Finally, studies are conducted to predict or monitor the effectiveness of treatments: they are particularly interested in pharmacogenetics and the search for anti-drugs.
2. Psoriatic arthritis (PR)
This rheumatism is associated in 90% of cases with skin or nail psoriasis (or familial).
But there is no parallelism between skin and joint disorders that are totally independent of each other.
Symptoms
Psoriatic arthritis is an Ankylosing spondylitis (AS) because there is an involvement of enthesitis very often associated with synovial involvement. Clinically, this is manifested by inflammatory spinal pain but rather beginner cervical, talalgia, sternal pain, fingerlings (fingers or toes in sausage) and arthritis of the joints of the members more frequent than in ankylosing spondylitis ( SPA).
Diagnostic
An inflammatory syndrome is quite common on the blood test, there are no known autoantibodies. The genetic terrain is variable: HLA B 16-17 or 27. X-rays, normal at the beginning, will show in severe forms lesions of ankylosis of entheses and destruction of arthritis of the limbs. But again, the evolution by successive pushes is capricious and variable from one patient to another with risk of stiffness of the spine and deformities of the hands and feet.
3- Reactive arthritis
Reactive arthritis affects mainly young subjects, in the form of migrating oligo-arthritis (1 to 3 joints), uveitis and sometimes inflammatory rachialgia. They are preceded 2 to 3 weeks before by a uro-genital or digestive (diarrhea).
Diagnostic
The inflammatory syndrome is frequent, the HLA B 27 gene often associated. The urogenital or digestive germ (Chlamydia, Mycoplasma, Shigellae, Salmonella, yersinia) should be investigated.
Evolution
The evolution under treatment (with antibiotherapy) can be done towards the cure, sometimes the recurrence, more rarely towards a true spondylarthritis ankylosing (SPA).
The evolution under treatment (with antibiotherapy) can be done towards the cure, sometimes the recurrence, more rarely towards a true spondylarthritis ankylosing (SPA).
4- Ulcerative colitis (UC) and Crohn's disease
These are diseases of the digestive tract (inflammatory enthérocolopathies) that can be associated with articular lesions such as spondylarthritis (SAI) with oligo or mono arthritis and involvement of entheses.
The search for bloody diarrhea must therefore be systematic during the interrogation; Digestive diagnosis requires colonoscopy. Management must take into account both diseases.
5- Rheumatism of palmoplantar pustulosis and SAPHO (Synovitis, Acne, Pustulose, Hyperostosis, Osteitis)
They are close to psoriatic arthritis but much rarer.
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