Ankylosing Spondylitis has insidious onset and back pain is the first symptom-Prof. Asim Khan

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 Pakistan Society for Rheumatology’s 19th Int. Conference

Ankylosing Spondylitis has insidious onset and
back pain is the first symptom - Prof. Asim Khan

Its prevalence in Pakistan could be between 0.5 to 1% of population
and X-Ray evidence is not necessary to diagnose these patients

Anti TNF therapy should only be used by
rheumatologists and not every physician

LAHORE: Ankylosing Spondylitis is a serious disease, it has insidious onset and back pain is the first symptom. It is different from rheumatoid arthritis. Hip joint involvement is quite common and its prevalence in Pakistan could be between 0.5 to 1% of the population. X-Ray evidence is not necessary to diagnose these patients because it takes time to show evidence on X-Ray. This was stated by Prof. Asim Khan Prof. Emeritus at Case Western Reserve University, Cleveland, Ohio United States. He was delivering his state of the art lecture in the inaugural session of Pakistan Society for Rheumatology’s 19th annual international conference held at Lahore from April 10-12, 2015.

  

Prof. Humayun Maqsood Principal Fatima Memorial Medical & Dental
College presenting a mementoe to Dr. Asim Khan during the
rheumatology conference held at Lahore recently.

It will be interesting to note that Prof. Asim Khan himself suffered from this disease at the age of twelve years and it was picked up and diagnosed by Prof. M. Akhtar Khan. Prof. Asim Khan then decided to specialize in this disease after graduation and has suffered from ankylosing spondylitis for the last fifty nine years.  He had a total hip replacement arthoplasty forty years ago which was again revised recently. Ankylosing Spondylitis, Prof. Asim Khan said  improves with exercise but in case of chronic back pain, there is no improvement with rest. Pain at night could be very severe. In Pakistan, Prof. Asim opined the disease onset may be even at a younger age.  Some children may present with inflammation of attached ligaments attached to knee cap. Damage of joint results in sacroilitis. Pelvic X-ray should be ordered and not of lumbosacral joint which will show abnormality. Inflammation then goes on to lumbar spine and with progression of inflammation neck can also get involved. He then showed some slides with structural damage in ankylosing spondylitis. Pain is worse at night. I was fortunate enough since Prof. Akhtar Khan diagnosed my case when I was just twelve years old after careful history and physical examination.  Prof. Akhtar Khan, Prof. Asim stated, is not a physician who starts looking at his watch when the patient talks too much. He then discussed the diagnostic value of some of the clinical features. Almost 80% of patients will have inflammatory back pain. Your suspicion should triple if the patient is young with acute episode of emergency pain and uvitis.  One should be much more suspicious if family history is positive. More features you have, more convinced you are.

Continuing Prof. Asim Khan said that positive family history, acute anterior uvitis, ulcerative colitis, Chrone’s Disease, Psoriasis, and Inflammatory Bowel Disease are some of the red flags. One can recognize this disease from history and clinical examination. It is more common in men than women. X-Rays may be normal as it takes some time to show evidence on X-Ray.  MRI of pelvis is usually asked for. He also talked about the concept of axial SPA. Hip joint damage shortens the life and the patients die young. HLA-B27 test, he stated, is positive in 80% of the patients. Reactive arthritis is seen in 30-70% of the patients. Negative test, he cautioned, does not mean the absence of the disease. Do not ask for this test if you have knowledgeable people. Prevalence of HLA B27 test is not 100% specific.  Doctor, Prof. Asim Khan opined is not healer but an educator but we usually negate that aspect. Patient education, physical therapy, exercise, rehabilitation programmes are all very effective and useful. Patients have formed their own help groups overseas. If there is no response to NSAIDs after two weeks, it is better to change the NSAID. These NSAIDs do slow down the progression of the disease on X-Ray. Patients should be advised to keep proper posture.

Speaking about the drug therapy Prof. Asim Khan mentioned the use of TNF blockers the biological drugs. Anti TNF therapy, he emphasized should only be used by rheumatologists and not every physician. Tuberculosis is quite common in Pakistan and it has not yet been controlled. This disease does shorten life. We need excellent health care set up. Treatment should be with No. 1 drugs but to begin with most of these patients do not have money to buy these expensive drugs. TB is highly prevalent hence we must help patients not to worsen their disease. He advocated judicious use of the drugs. Patient’s compliance with salfasalazine is better and it should be used for four to six month. Bone scan of neck is not good in young patients.  It may be helpful in some one who feels that the neck is hurting. Bone imaging has some role but it cannot pick up early damage, Prof. Asim concluded.

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