Spondyloarthropathy Explained

Spondyloarthropathy (sometimes referred to as spondyloarthritis) refers to a group of inflammatory rheumatic diseases that includes ankylosing spondylitis and psoriatic arthritis. The predominant symptom among them is joint pain and inflammation, sometimes affecting the spine. In some cases, these diseases can become systemic, causing inflammation in the eyes, gastrointestinal tract, and skin.

Spondyloarthropathies have been linked to several genes; some experts believe that a combination of genetic and environmental factors may trigger their development.

The following six conditions are classified as spondyloarthropathies. Each has its own set of symptoms and risk factors, though there is a great deal of overlap.

Ankylosing spondylitis is a type of arthritis primarily characterized by chronic inflammation of the joints and ligaments of the spine, causing pain and stiffness. In severe cases, vertebrae may fuse (a condition referred to as ankylosis), resulting in a rigid and inflexible spine. Abnormal posture may be a consequence. Other joints may be involved including the hips, knees, ankles, neck, or shoulders. The disease may also have systemic effects (affecting various organs of the body), including fever, fatigue, and eye or bowel inflammation. Heart or lung involvement is rare but possible.

Ankylosing spondylitis affects males two to three times more often than females; onset is typically in the teens or 20s.

A gene known as the HLA-B27 gene is thought to be a risk factor. Certain populations are more likely to have this gene, including Native American tribes in Canada and the western United States, as well as Alaskan and Siberian Eskimos and Scandinavian Lapps. Family members of those with the gene are also at higher risk than those without it.

Psoriatic arthritis is a type of arthritis associated with psoriasis (a skin condition characterized by red, patchy, raised, or scaly areas) and chronic joint symptoms. The symptoms of psoriasis and joint inflammation often develop separately. (In 85 percent of patients, symptoms of psoriasis precede arthritis symptoms. Arthritis develops before psoriasis in up to 15 percent of patients.)

Psoriatic arthritis typically develops between the ages of 30 and 50. Men and women are equally affected by the disease, which is known as an autoimmune disease. Heredity may also play a role, with 40 percent of patients having a family member with psoriasis or arthritis,

Reactive arthritis, formerly known as Reiter's syndrome, is a form of arthritis that can result in two to four weeks after a bacterial infection. It is characterized by swelling in one or more joints. While most cases resolve on their own, some patients do get persistent disease or symptoms that remit and relapse.

The bacteria most commonly associated with reactive arthritis are:

• Chlamydia trachomatis: This is spread through sexual contact. The infection may begin in the vagina, bladder, or the urethra.
• Salmonella, Shigella, Yersinia, and Campylobacter: These bacteria typically infect the gastrointestinal tract.

Reactive arthritis can occur in anyone if they are exposed to these organisms and tends to occur most often in men between ages 20 and 50. Some patients with reactive arthritis carry the HLA-B27 gene which is also associated with ankylosing spondylitis; people with weakened immune systems due to AIDS and HIV are also at risk for this condition.

Antibiotics are used to control the initial infection. In some cases, arthritis symptoms may last up to a year, but they are usually mild and do not interfere with daily life. A few patients will have chronic, severe arthritis that is difficult to control and may cause joint damage.

Enteropathic arthritis is a chronic type of inflammatory arthritis associated with the inflammatory bowel diseases ulcerative colitis and Crohn's disease. The most common symptoms are inflammation of the peripheral joints and some abdominal discomfort. The entire spine can become involved in some patients.

When a patient has signs of spondylitis—but does not meet certain criteria that are necessary for a definitive diagnosis of ankylosing spondylitis or another spondyloarthropathy—a diagnosis of undifferentiated spondyloarthropathy may be given. In some cases, undifferentiated spondyloarthropathy may evolve into one of the more easily identifiable types of the disease.

Juvenile spondyloarthropathies are a group of conditions that develop before age 16 but may last throughout adulthood. They include undifferentiated spondyloarthropathy, juvenile ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and spondylitis of inflammatory bowel diseases.

Typically, juvenile spondyloarthropathies involve the lower extremities, with pain and inflammation of the hip, knees, lower back, heels, and toes—usually asymmetric—being the first symptoms. In adulthood, the spine is more likely to be involved. It is not known exactly what is responsible for the development of these conditions, but heredity is thought to play a role.

If your doctor suspects you have a form of spondyloarthritis, the first thing he or she will do is perform a physical exam and ask you about your medical history.

Testing will be necessary to come to a formal diagnosis and may include:

• X-rays: Changes in the sacroiliac joints—the joints connecting the sacrum and the top of the pelvis—are often a key sign of spondyloarthritis.
• Magnetic resonance imaging (MRI): If X-ray results are not clear, an MRI may show the signs more accurately.
• Blood tests: A blood test can determine whether you have the HLA-B27 gene. (Having the gene, however, does not necessarily mean you will develop spondyloarthritis.)

Spondyloarthropathies cannot be cured, but the symptoms can be managed. Your treatment plan will depend on which type of spondyloarthropathy you have been diagnosed with and your specific symptoms. The options include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Various NSAIDS are effective for temporarily relieving pain and inflammation from spondyloarthritis. These include over-the-counter drugs such as Advil (ibuprofen) and Aleve (naproxen). Prescription NSAIDs, which are more potent, are available as well.
• Corticosteroid injections: When joint swelling is not widespread, injections of a corticosteroid medication directly into the joint or membrane surrounding the affected area can provide quick relief.
• Disease-modifying antirheumatic drugs (DMARDs): If NSAIDs and corticosteroids aren't effective, your doctor may prescribe disease-modifying antirheumatic drugs to relieve symptoms and prevent joint damage. DMARDs are most effective for arthritis that affects the joints of the arms and legs. Methotrexate is one of the most commonly used drugs in this category.
• Tumor necrosis alpha blockers (TNF blockers): These medications target a specific protein that causes inflammation. They are often effective for arthritis in leg joints and the spine. One example of a TNF blocker is Humira (adalimubab). These drugs can cause serious side effects, including raising the risk of serious infections.

In some cases, spinal surgery may be needed to relieve pressure on the vertebrae; this is most common with ankylosing spondylitis. When inflammation destroys the cartilage in the hips, surgery to replace the hip with a prosthesis, called total hip replacement, can relieve pain and restore the joint’s function.

Living with a form of spondyloarthritis puts you at risk for certain systemic complications. These include:

• Uveitis, an inflammation of the eye causing redness and pain. This affects approximately 40 percent of people with spondyloarthritis.
• Inflammation of the aortic valve in the heart
• Psoriasis, a skin disease often associated with psoriatic arthritis
• Intestinal inflammation
• Osteoporosis, which occurs in up to half of patients with ankylosing spondylitis, especially in those whose spine is fused. Osteoporosis can raise the risk of spinal fracture.

Despite the impact that spondyloarthritis can have on your day-to-day life, most people are able to live a full life with the condition. Regular exercise can help keep the joints healthy. Ask your doctor which forms of exercise are appropriate for you, or seek the advice of a physical therapist. And if you smoke, work to quit, as the habit can worsen your case.