Ankylosing spondylitis: diagnosis and medical treatment

2021-07-20 05:11 PM

Several factors are important in the pathogenesis of ankylosing spondylitis, the disease has diverse clinical manifestations, involving a number of different structures

Ankylosing spondylitis is the most common chronic inflammatory arthritis in the seronegative spondyloarthropathy group. Ankylosing spondylitis has a close relationship with the HLA-B27 leukocyte antigen factor (80-90%) of the antigenic system, which is common in men (80-90%).

Young (under 30 years old accounts for 80%).

The disease greatly affects the joint mobility function, working ability, daily life, quality of life of the patient and is the cause of disability if not diagnosed and treated promptly.

The cause of ankylosing spondylitis is currently unknown.

Definite diagnosis

Based on the New York diagnostic criteria of 1984:

Clinical standards

History or current of low back or low back pain lasting more than 3 months.

Limit low back movement in all 3 postures stooped, supine, tilted, and turned.

Decreased thoracic expansion.

X-ray standards

Unilateral sacroiliitis stage III or IV Bilateral sacroiliitis stage II or higher.

The diagnosis of ankylosing spondylitis is confirmed by the presence of one clinical and one radiological criterion.

To diagnose the disease and monitor the progression of the disease, it is necessary to do more tests for the inflammatory response (erythrocyte sedimentation rate, C-reactive protein).

In the early stages of the disease to help confirm the diagnosis, if possible, only the positive HLA-B27 test in > 80% of cases), magnetic resonance imaging (MRI) of the sacroiliac joints. Family members may have diseases in the group of seronegative spondylarthritis (ankylosing spondylitis, psoriatic arthritis, reactive arthritis...).

Differential diagnosis

Spine diseases: bacterial disc spondylitis, tuberculosis: bacterial infection, vertebral body and disc damage on X-ray film...

Spondylolisthesis: seen in the elderly, the image of bone spurs in the vertebral body, the tests of the inflammatory response are normal.

Peripheral joint diseases: tuberculosis of the hip (patients with pain and mobility limitation are usually on one side of the hip, bone and joint damage on film, there may be associated pulmonary tuberculosis...), hip degeneration ( tests for normal inflammatory response, bone spur lesions, etc.).

Treatment purpose

Control pain and inflammation, maintain movement function of joints, columns

life and prevent deformity of joints and spine.

Movement therapy

Counseling and guiding patients on joint and spine mobility exercises, participating in physical activities (swimming, walking, cycling...) suitable to the disease condition and stage of the disease.

Instruct the patient to practice breathing, lie in the correct position (do not use high pillows, do not lie on soft cushions, do not lie on the knees...).

Physiotherapy treatment: infrared radiation, ultrasound, hot mineral water bath, mud bath, massage...

Drug treatment

Analgesic

You can choose from one of these pain relievers:

Acetaminophen (paracetamol, Dolodon, Tylenol...) 0.5g x 2 - 4 tablets/24 hours.

Floctafenine (Idarac) 200mg x 2 tablets/24 hours.

Non-steroidal anti-inflammatory drugs

One of the following non-steroidal anti-inflammatory drugs can be selected depending on the response of the drug, disease status, and economic ability of the patient (note absolutely do not combine drugs in the group because it does not increase the therapeutic effect). treatment but has many undesirable effects):

Diclofenac (Voltaren) 50mg x 2 tablets/day divided into 2 or 75mg x 1 tablet/day after a full meal.

75mg/day intramuscular injection can be used for the first 2-3 days when the patient is in severe pain, then switch to oral.

Meloxicam (Mobic) tablet 7.5mg x 2 tablets/day after eating or as an intramuscular injection 15mg/day x 2-3 days if the patient has a lot of pain, then switch to oral route.

Piroxicam (Felden) 20mg tablets or ampoules, take 1 tablet/day, orally after meals or intramuscularly, 1 ampoule per day for the first 2-3 days when the patient has severe pain, then switch to oral.

Celecoxib (Celebrex) tablets 200mg dose 1 to 2 tablets / day after a full meal. Should not be used in patients with a history of cardiovascular disease and with greater caution in the elderly.

Slow-acting drugs (basic treatment)

Sulfasalazine (Salazopyrine) 1000 - 2000mg/24 hours.

Methotrexate 7.5 - 15mg/week: for cases of peripheral ankylosing spondylitis.

Corticosteroids

Treatment of topical corticosteroids: injection of joints, injection of tendon attachment points (hydrocortisone acetate: 125mg/5ml, Depo - Medrol 40mg/ml...).

Systemic corticosteroid treatment in cases of severe disease unresponsive to non-steroidal anti-inflammatory drugs or patients dependent on corticosteroids, the dose is 1 - 1.5 mg/kg/24 hours, and the dose is gradually reduced according to the patient's condition. progress and response of the patient.

The new class of biological drugs: monoclonal antibodies against tumor necrosis factor-alpha (TNF alpha) (Remicade, Entanecept...) to treat cases resistant to therapeutic drugs.

Combination therapy with muscle relaxants

Patients taking methotrexate: folic acid 5mg x 2 tablets/week.

Patients presenting with gastritis - duodenal ulcer: omeprazole 20mg/24 hours.

Patients taking corticosteroids, with osteoporosis: calcitonin (Miacalcic, Rocalcic) 50-100UI/24 hours (intramuscular or nasal spray), bisphosphonates (Fosamax, Alenta...) 70mg/week, calcium 0.5-1g/24 hours.

Patients with secondary osteoarthritis: diacerein (Artrodar) 50-100mg/25h, glucosamine sulfate (Viartril-S, Bosamin, Lubrex-F...) 1g-1.5g/24 hours, chondroitin 0.5-1g /day.

Orthopedic Surgery

Hip replacement, knee replacement, the release of an adhesive or deformed joint.

Prevention

Educating and guiding patients and patients' family members to have knowledge about the disease to properly implement the treatment course and monitor the treatment process.

Apply treatment measures to limit disease sequelae: prevent muscle atrophy, ankylosing spondylitis, and improve the patient's quality of life.