Co-Manifestations in nr-axSpA
MAY 28, 2020
Sergio Schwartzman, MD: Philip, we've touched on this a little bit, but if we look at the comorbidities that are associated with nonradiographic axial spondyloarthritis, my first question to you is what are these? My second question to you that bears on Atul's point about a spectrum is, are they different than what we see in radiographic axial spondyloarthritis?
Philip J. Mease, MD: Sergio, this is a very important issue to talk about comorbidities as well as associated condition. It is imperative that we step outside of our, our narrow shoes, as rheumatologists, into a broader place of being clinicians, physicians for patients. This is because some of these comorbidities are very important and need to be attended to—they need to be recognized.
Many times, the patient may not have a primary care situation where they're getting these things addressed. So, we have to bird-dog whether they're taking care of. Let's start with what I call associated conditions. The big 3 are uveitis, psoriasis, and inflammatory bowel disease. I call them associated conditions because all of them have pathologic mechanisms that are shared with the basic pathologic mechanisms of axial spondyloarthritis.
We see a higher prevalence of all of these in both radiographic axial spondyloarthritis as well as nonradiographic axial spondyloarthritis. I should acknowledge that many of the more definitive investigations of comorbidities and associated conditions have been done in an ankylosing spondylitis population historically, so patients with radiographic disease. We have much fewer in the way of definitive studies in the nonradiographic population.
But the few that have been done have suggested that there is a similar degree of comorbidity in the non-radiographic population. I remember 1 study from Europe that showed a little bit less in the way of uveitis in a non-radiographic population than radiographic. But I think the take-home message for the listeners here should be to assume that these issues can be present, and we need to attend to looking for them.
Uveitis is one of Sergio’s special areas. It can sometimes be a gateway into the diagnosis. If it has to ophthalmologist who was seen a patient with uveitis in front of them, maybe they get HLA-B27 [human leukocyte antigen B27] as part of their laboratory workup. But it’s important to ask a few questions of the patient such as, “Do you have any problems with back pain?” Getting them referred to a rheumatologist is also important.
Same with IBD [inflammatory bowel syndrome]—if the patient has evidence of Crohn disease or ulcerative colitis having the gastroenterologist, ask a few questions of the patient to get them to go see a rheumatologist. There was even a recent study done at NYU [New York University], in your city, Sergio, where they looked back on the MRI [magnetic resonance imaging] scanning that's done of Crohn's disease patients—so-called MR [magnetic resonance] enterography—and found that there was evidence of sacroiliac inflammation in many of the patients that had just been missed by the radiologist when they were interpreting the MRI scan.
So there are various avenues that can improve getting patients with these associated conditions to rheumatologist for better management of their musculoskeletal disease.
Transcript Edited for Clarity