There are individuals with symptomatic disease without radiological evidence-Dr. Asim Khan


 Non radiological spondyloarthritis

There are individuals with symptomatic disease
without radiological evidence - Dr. Asim Khan

Patients should not be exposed to too much
radiation as it has its own adverse effects

KARACHI: Dr. Asim Khan from USA was the first speaker in the second session on day- 2 of the Rheumatology conference organized by Pakistan Society for Rheumatology. The topic of his presentation was Non-Radiological Spondyloarthritis. He pointed out that in United States about 50% of rheumatologists are women as it is good specialty for women. In Pakistan we need more paediatric rheumatologists. I myself suffered from Ankylosing Spondylitis at the age of twelve years and it was misdiagnosed for many years. He then gave historical look at classification criteria for Axial SPA.

Dr. Arif Alvi President of Pakistan was chief guest in the inaugural session of Rheumatology
Conference organized by PSR at Karachi last month. Picture shows him presenting a
memento to Dr. Abdul Bari Khan. Dr. Mahfooz Alam is also seen on extreme left.

He then discussed the ankylosing spondylitis classification criteria in patients who have already been diagnosed. Prevalence of disease is not important as patients have disease and they have been diagnosed. Objective is to provide unique language for researchers. Many females had the disease but their X-ray was normal. There are individuals with symptomatic disease without radiological evidence of disease. This disease, Dr. Asim stated has a very wide spectrum. MRI may show active sacroillitis. It takes a long time to be diagnosed as people wish to see evidence on X-ray. He then talked about modified New York criteria for Ankylosing Spondylitis. It is based on sacroillitis on X-ray or MRI plus SPA features or HLA-B27.

Age of onset for inflammatory back pain is forty years of age. Pain is worse at night. There is improvement with exercise but no improvement with rest. About 20% of patients do not present with back pain hence it becomes difficult how to diagnose axial spondyloarthritis. These patients show good response to NSAIDs. Clinical features include family history of disease. In case of chronic low back pain, refer the patient to rheumatologist for proper evaluation. In case of inflammatory type, there is morning stiffness, pain at night and early morning which improves with exercise.

These patients should be referred to the rheumatologists. Now this disease is diagnosed much early. He advised the physicians not to expose the patient to too much radiation as it has its own adverse effects. One can see many CTs and MRIs but the imaging is not done properly. Since this disease can be multifactorial, whole body MRI is very helpful. Women are more likely to present with atypical features. They can present with shoulder pain and not by low back pain. Women may be misdiagnosed as suffering from fibromyalgia. Women often suffer longer delays in early diagnosis. He then discussed in detail the challenges in diagnosis and management and highlighted the importance of education, exercise, physical therapy, rehabilitation, patient associations and self help groups. NSAIDs work very well their response and good effects will be seen in a week’s time. It is important to find the NSAIDs which are effective. One should select the right NSAID which should be taken once or twice daily. Sulfasalazine should not be given for more than five to six months. Local steroids, TNF blockers, analgesics and finally surgery are recommended.

Treat to Target Disease Management

Dr. Asim’s second presentation was on Treat to Target Disease Management. He discussed the ASDAS score from very high disease activity to high disease activity, low disease activity and inactive disease. Increased disease activity may be associated with greater degrees of structural progression. Step down strategy is needed in Treat to Target disease management for more than six months. Radiographic progression of the disease is strongly dependent on male gender, smokers. Smoking makes Ankylosing Spondylitis worse. Smoking is also a risk factor for rheumatic diseases. NSAIDs may not be enough and one may need biological. Smoking triples bad outcome with normal CRP but it is double in elevated CRP. Disease activity in male smokers has tenfold effect on radiographic damage in comparison with female. Probiotics, pre-biotics, antibiotics and their usefulness was also discussed. Clinical trials and numerous international studies have showed no efficacy of probiotics. As regards pre-biotics, there has been no reported trial of their safety. He concluded his presentation by stating that early referral and proper diagnosis of Axial SPA are primary objectives. Now we have much more effective treatments available. Achieving tight control of disease improves outcome and it may also retard the disease progression.

Dr. Asim Khan, Prof.Abid Farooqui and others speaking at the Rheumatology conference
held from 14-17th March 2019. 

Prof. John Axford from UK spoke about Myalgias which was interactive case based studies. He was of the view that always expect which is expected. This disorder affects a large number of people. It affects heart, lungs and endocrine. Peak is seen at age seventy five years and it is seen more in women. Aching , morning stiffness, abrupt onset, decreased range of motions, muscle tenderness, hand swelling, fatigue, depression, anorexia, weight loss, low grade fever were mentioned as some of the non-specific systemic signs of polymyalgia rheumetica.

Prof. Abid Farooqui, Dr. Muhammad Saeed and other delegates making presentations
during the Rheumatology conference organized by PSR at Karachi last month.

He then presented some interesting case studies of sarcoidosis. Its prevalence is about 700/100,000, is seen less common in Asians. Most often these patients are referred to the surgeons. A trial of steroids may be useful. One can start with 15mg a day, then tapper to 10mg followed by one mg. Methotrexate has high drop out hence use its low dose. He then presented a few patients suffering from facit joint inflammation osteomylitis, acute vasculitis, and acute giant cell arteritis. Steroids and DMARDs are found quite useful.

In case of Taka Yashu’s disease a trial of steroids may be helpful. Almost 50% of patients stop steroids after one or two years. Some require longer stable dose of 5mg/day. One should never be afraid to suggest diagnosis, it may be wrong but it may also be right. It is important to test one’s diagnosis. Trial of steroids is diagnostic and one should encourage rheumatology referrals. He also referred to RSM RCP Global Initiative in which Fatima Memorial Hospital in Lahore is already participating. Other institutions are also welcome to join this initiative. Responding to a question as to how long one should continue treatment for myalgia, he said, stopping the treatment too early may have problems. Hence one can stop it when the patient feels better.

Group Photograph taken during the Rheumatology Conference held at Karachi last month
shows Prof. Kirmani, Prof. Terrence Gibson, Prof. Rukhsana Zuberi, Dr. M. Saeed,
Prof. Sumaira Farman, Prof. Mahfooz Alam, Prof. Shakeel Baig and others.

Prof. Hassan Tahir from UK spoke about the management of Axial Spa and presented the clinical trials the real world data. He pointed out that studies have shown that 50% of the patients are satisfied while the remaining 50% are not happy. There are about 40% patients with unmet needs. There are patients whose response to treatment is inadequate. Speaking as to why patients fail on anti-TNFa he said that drug survival and retention is decreased after switching treatment with biologics. About 50% patients will have sub-optimal response. New therapeutic options are now available. IL 17A is inflammatory effector. It has shown to be effective in psoriasis, Ankylosing Spondylitis and it is approved for this indication in Pakistan. He then shared the details of various clinical trials. Measure 1-4 is Phase-III trials of this drug. It offers rapid and sustained improvement in signs and symptoms of Ankylosing spondylitis. Response was visible in one week. Almost 60% of patients getting this drug achieved a significant response at three years. About 64% of patients receiving this drug achieved an ASAS40 response. It was effective in those patients who already had biological treatment. About 70% of patients who had prior biologic treatment did not progress radiologically. There was no progression of disease after four years. There was low incidence of discontinuation due to adverse events. Safety reports in psoriasis were also highlighted. The drug is well tolerated for upto three years. His conclusions were that this drug provides relief of signs and symptoms which is sustained at three years. It offers rapid relief and was the first biologic to show efficacy. There is no radiological progression of disease with its treatment.