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Canadian Rheumatology Association, Spondyloarthritis Research Consortium of Canada publish recommendations for treatment of SpA

Saturday, November 24 2007 | Comments

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What's This? The Canadian Rheumatology Association and the Spondyloarthritis Research Consortium of Canada published treatment recommendations for the management of patients with spondyloarthritis.

According to the organizations, management recommendations for SpA should be based on expert clinical evaluation by a rheumatologist, in addition to a pelvic radiograph/computed tomography scan indicating sacroiliitis or magnetic resonance imaging results that indicate evidence of sacroiliac joint or spinal inflammation.

On an individual patient basis, SpA treatment should be tailored to current manifestations of the disease; current symptoms, clinical findings, and prognostic indicators; disease activity; pain; function, disability, and handicap; structural damage, hip involvement, and spinal deformities; patient characteristics such as comorbidities and concomitant drug use; and patient preferences. The goal of treatment should be to control pain and inflammation and prevent radiographic damage and disability.

Monitoring should include laboratory tests, imaging, and measurement of clinical variables, including the use of questionnaires such as the Bath Ankylosing Spondylitis Disease Activity Index and the Bath AS Functional Index. Clinicians should also take into account patients' participation in various types of activities when evaluating outcomes.

Nonpharmacologic treatment for patients with SpA should include patient education and regular exercise; individual and group physical therapy should be considered as well. When possible, these treatment options should occur in centers with special expertise in managing SpA. Self-help groups may also be useful.

When managing SpA pharmacologically, nonsteroidal antiinflammatory drugs should be employed as the first line of therapy in patients with pain and stiffness. A sufficient trial should include >=3 NSAIDs, each administered during >=2 weeks at the accepted maximum dosage, if tolerated; a gastroprotective agent can be used in patients at increased risk of gastrointestinal complications. COX-2 inhibitor therapy should be used only in patients at increased risk of gastrointestinal complications who do not respond sufficiently to traditional NSAID therapy. Analgesics may also be considered to control pain but should not replace NSAIDs, as they do not control inflammation.

Corticosteroid injections at the local site of musculoskeletal inflammation may be considered; however, evidence does not support the use of systemic corticosteroids for axial or peripheral disease.

Evidence has not shown traditional disease-modifying antirheumatic drugs, including sulfasalazine and methotrexate, to be effective in treating axial disease. However, sulfasalazine in doses of <=3 g/day may be considered in patients with peripheral arthritis for <=3 months (along with monthly complete blood counts and liver enzyme tests), and methotrexate in doses of <=25 mg/week may be considered in patients with peripheral arthritis for <=3 months (along with monthly complete blood counts and serum alanine aminotransferase and alkaline phosphatase tests every 2 months; folic acid should be taken at a dose of 1 mg/d to 5 mg/d).

Anti-tumor necrosis factor agents may be used in patients with persistently high disease activity despite conventional treatments. All currently available anti-TNF agents are appropriate to treat SpA. Continuation of anti-TNF therapy should be based on response by 16 weeks.

For surgical management, the organizations recommend consideration of total hip arthroplasty for patients with refractory pain or disability and radiographic evidence of structural damage, independent of age. Spinal surgery may also be of value in selected patients. (Maksymowych WP, et al. J Rheumatol 2007;34:2273-2284.)

This information may concern uses that have not been approved by the Food and Drug Administration.

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