What you need to know about Spondyloarthritides
Spondyloarthritides are a group of arthritic diseases
that share several common features. They can cause inflammation of the
spine; however, other joints may be affected. The tendon and ligament
tissue near the spine or joint is also involved. A high percentage of
people with these diseases share a similar gene called HLA B27. Finally,
many patients also have inflamed areas in the eye, bowel, genital tract
The spondyloarthritides include:
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis/Reiter's syndrome
- Enteropathic arthritis
- Undifferentiated: Patients with features of more than one disease who do not fit in the
defined categories above
Ankylosing spondylitis (AS)
AS is a chronic, systemic, inflammatory disease of the joints and
ligaments of the spine. Other joints may be involved. This typically
results in pain and stiffness in the spine. The disease may be mild to
severe. The bones of the spine may fuse over time causing a rigid spine.
Early diagnosis and treatment may help control the symptoms and reduce
debility and deformity.
Who gets AS?
The onset is typically in late adolescence to early adulthood. It is
rare for AS to begin after age 45. The disease is more common in men and
in Caucasians. The incidence is 1 in 1000 persons. About 90% of people
with AS have the HLA B27 gene.
What causes AS?
The cause of AS is unknown although there appears to be some genetic
component. AS is associated with the HLA B27 gene but it is unclear why.
The gene is seen in about 8% of normal Caucasians. There are no known
infectious or environmental causes.
What are the signs and symptoms?
Early on, there is pain and stiffness in the buttocks and low back due
to sacroiliac joint involvement. Over time, the symptoms can progress up
the spine to involve the low back, chest and neck. Ultimately, the bones
may fuse together causing limited range of motion of the spine and
limiting one's mobility. Shoulders, hips and sometimes other joints may
be involved. AS may affect tendons and ligaments. For example, the heel
may be involved with Achilles tendonitis and plantar fasciitis. Since it
is a systemic disease, patients can get fever and fatigue, eye or bowel
inflammation, and rarely, there can be heart or lung involvement. AS is
typically non life-threatening. Usually, it is a slowly progressive
disease. Most people are able to work and function normally.
How is AS diagnosed?
The diagnosis is typically suspected by the doctor based on the signs
and symptoms. The doctor will take a thorough history and do a physical
examination. X-rays, especially those of the sacroiliac joints and spine
can be confirmatory. The HLA B27 gene may be checked by a blood test,
but its presence or absence does not ultimately confirm or reject the
How is AS treated?
At this time there is no known curative treatment. Goals of treatment
are to reduce pain and stiffness, slow progression of disease, prevent
deformity, maintain posture and preserve function.
Exercise programs are an essential part of the
treatment. Patients may be referred for a formal physical therapy
program. Patients with AS are given daily exercises for stretching and
strengthening, deep breathing exercises and posture exercises to avoid
stooping and slumping.
Medications are also used to treat AS. Non-steroidal
anti-inflammatory drugs (NSAIDs) are traditionally used to control
symptoms. Steroids, such as cortisone or prednisone, are rarely used,
except for with injections to a tendon or joint. Sometimes, medications
that are normally used for rheumatoid arthritis, such as sulfasalazine
or methotrexate, may be used. These appear to be less helpful for the
spine disease. More recently, the biologic anti-TNF-a agents etanercept
(Enbrel®), adalimumab (Humira®), and infliximab (Remicade®)
have been approved for use in AS. These drugs may not only help symptoms
but also slow the progression of the disease. They are only given as
IV's in the doctor's office or by self-administered shots at home.
Surgical options are limited. There are no specific
surgical interventions for the spine. Sometimes, in severe cases,
replacement of the shoulder or hip joint is beneficial.
Reactive arthritis (ReA)
Reactive arthritis is a non-infectious inflammation of one or several
joints. It may be self-limited, relapsing or chronic. The condition
sometimes follows an infection of the gastrointestinal or genitourinary
system. There may be other non-joint features such as eye, genital
tract, bowel or skin inflammation.
The term Reiter's Syndrome is an older term that most
rheumatologists have now replaced with Reactive Arthritis. Reiter's
Syndrome was a term originally used to refer to a syndrome of
non-infectious eye, genital and joint inflammation following a previous
bowel or genital bacterial infection. All of these features are rarely
Who gets reactive arthritis?
ReA may follow an infection of the genital tract or bowel, but this is
not always identified. It is more common in men and Caucasians. ReA is
rare after the age of 50. The disease is associated with the HLA B27
gene in 50 - 80% of patients.
What causes reactive arthritis?
The cause of ReA is unknown. It is associated with the HLA B27 gene, but
it is unclear why. It is also unclear why ReA is sometimes associated
with infection. (Bacterial infections of genital tract with Chlamydia or
gastrointestinal tract with Shigella, Salmonella, or Campylobacter).
What are the signs and symptoms of reactive arthritis?
ReA may follow several weeks after a genital tract or bowel infection.
The patient may have acute swelling, pain and redness in one or more
joints. Typically, it is more common in the lower extremity joints.
During the joint symptoms, one may also have non-infectious genital
tract, skin or eye inflammation. ReA patients may have tendonitis,
especially of the heel. There may be spine involvement (like ankylosing
spondylitis). Traditionally, ReA is self-limited to 3 to 12 months, but
up to 50% may have relapsing or chronic disease. The disease is not life
threatening, and most people are able to work and function normally.
How is reactive arthritis diagnosed?
The diagnosis is typically made by a doctor taking a thorough history
and physical examination. A swollen joint may be aspirated to rule out
an infection or gout. There is no specific test for the diagnosis of
ReA. The HLA B27 gene may be checked by blood test in selected cases,
but it is not diagnostic.
How is reactive arthritis treated?
At this time, there is no curative treatment. Any existing infection, if
discovered, should be treated. The role of routine antibiotics is
controversial. Physical therapy, stretching and exercise are prescribed.
Non-steroidal anti-inflammatory drugs (NSAIDs) are given for pain and
stiffness. Steroid injections to involved tendons or joints can help
relieve pain and inflammation. In chronic or relapsing cases, similar
treatments to rheumatoid arthritis can be considered to include
methotrexate, sulfasalazine and the biologic anti-TNF-a drugs (as listed
Enteropathic arthritis is peripheral joint or spine disease
associated with inflammatory bowel disease (IBD), such as Crohn's
Disease or Ulcerative Colitis.
Who gets enteropathic arthritis?
Enteropathic arthritis is seen in up to 10 - 20% of those with IBD. It
is more common in juveniles and young adults. The male to female ratio
What causes enteropathic arthritis?
The cause is unknown.
What are the signs and symptoms of enteropathic arthritis?
The arthritis typically occurs after the bowel disease is well
established. Rarely, the arthritis can start before IBD is diagnosed.
There is pain and swelling in one or more joints. Typically, the
arthritis occurs in the lower extremity joints. The arthritis may mirror
the activity of the bowel disease. There may also be spine involvement
(like ankylosing spondylitis). The HLA B27 gene is seen in up to 50%
with spine involvement. The spondylitis (spine involvement) is less
likely to correlate with the bowel disease activity. Patients may have
other systemic symptoms such as fever, skin or eye inflammation, and
oral ulcers. Enteropathic arthritis rarely causes joint destruction,
deformity or significant disability.
How is enteropathic arthritis treated?
Like the other spondyloarthropathies, the patient needs physical therapy
and exercise. Treatment of the bowel disease may help the peripheral
joints but not the spine. Removing the colon (colectomy) in ulcerative
colitis may "cure" the arthritis. One can use non-steroidal
anti-inflammatory drugs (NSAIDs), but there is a need to be aware of the
bowel effects. Local injection of steroids into joint(s) can be very
helpful. Oral steroids can be used in more severe cases. In resistant
cases, medications normally used to treat rheumatoid arthritis, such as
methotrexate, azathioprine (Imuran®) or sulfasalazine can be tried for the joints. Anti-TNF-a drugs, like adalimumab (Humira®) and infliximab (Remicade®) have shown benefit with joint and bowel
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