Indonesian woman’s rigid spine from Ankylosing Spondylitis

An Indonesian woman who suffers from a rare that has left her completely unable to move.

Pictures show 35-year-old Sulami a woman from the Sragen area of Central Java, in the grip of a disease known as ‘bamboo spine’ that has turned her completely rigid.

An Indonesian woman who suffers from a rare condition that has left her completely unable to move

Pictures show 35-year-old Sulami a woman from the Sragen area of Central Java, is suffering from a disease that has turned her completely rigid

Pictures show 35-year-old Sulami a woman from the Sragen area of Central Java, is suffering from a disease that has turned her completely rigid

According to the Health Department of Sragen, Sulami’s suffers from a rare genetic disorder, Ankylosing Spondylitis.

Her condition is so bad that she has to rely on help from her 90-year-old grandmother, Suginem, to care for her.

For the last 10 years, Sulami has not able to sit or even bend over her body, and has to use a stick in order to help her walk.

According to the Health Department of Sragen, Sulami's suffers from a rare genetic disorder, Ankylosing Spondylitis

According to the Health Department of Sragen, Sulami’s suffers from a rare genetic disorder, Ankylosing Spondylitis

Her condition is so bad that she has to rely on help from her 90-year-old grandmother, Suginem, to care for her

Her condition is so bad that she has to rely on help from her 90-year-old grandmother, Suginem, to care for her

For the last 10 years, Sulami has not able to sit or even bend over her body, and has to use a stick in order to help her walk 

For the last 10 years, Sulami has not able to sit or even bend over her body, and has to use a stick in order to help her walk


Ankylosing Spondylitis occurs when the spine and other areas of the body become inflamed.

It can initially cause back pain, stiffness and extreme fatigue.

There is no cure for AS and it’s not possible to reverse the damage caused by the condition.

However, treatment is available to relieve the symptoms and help prevent or delay its progression. In most cases treatment involves a combination of exercise, physiotherapy, and medication.

Around 70 to 90 per cent of people with AS remain fully independent, but in the worst cases it can leave people incapable of moving.

It does not effect life expectancy itself but is know to trigger other serious conditions, such as cardiovascular disease, spinal fractures, chest infections and kidney disease.



A Diagnostic Challenge: When Fibromyalgia Coexists with Ankylosing Spondylitis

A recent study published online in a supplement to Arthritis & Rheumatology looked at the prevalence of fibromyalgia among patients with ankylosing spondylitis, finding a high prevalence, at 43%. Lead investigator Marina N. Magrey, MD, of Case Western Reserve University and MetroHealth Medical Center in Cleveland here describes the study findings. Click here to download a detailed abstract of this study.

Further discussion of fibromyalgia in the context of other chronic disease is provided by Carmen Gota, MD, of Cleveland Clinic.

Magrey: We did this study to answer a very important clinical question, whether tools of disease activity in ankylosing spondylitis measure just the inflammatory pain or do they even measure fibromyalgia pain?

Ankylosing spondylitis is … it’s a chronic inflammatory disease that predominantly involves axial skeleton and is associated with human leukocytic antigen B27. It’s characterized by inflammation in the spine, peripheral joints, and entheses, resulting in pain, fatigue, and stiffness.

So despite significant progress made in the treatment of ankylosing spondylitis, there are many patients who continue to have persistent pain, and this pain may be related to their disease activity or may be unrelated to their disease activity, and in those patients, we think the pain may be coming from this chronic, nonarticular fibromyalgia syndrome.

It’s very important for the clinician to actually be able to detect fibromyalgia in these patients, because based on that, they could decide whether they want to continue treating these patients or de-escalate these patients.

Tools for Measurement

Now we do have two very reliable tools of disease activity in ankylosing spondylitis called Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and ASDAS. Both of these are patient-reported outcomes. ASDAS is an improved version of BASDAI, because it not only incorporates the patient-reported outcomes, but it also includes in it ESR and CRP, which is … values, which are more objectively reflecting inflammation.

Both of these tools measure fatigue, stiffness, back pain, tenderness, and peripheral joint pain. There have been some studies in the past which have actually shown that the Bath Ankylosing Spondylitis Disease Activity Index may not be specifically measuring inflammatory pain and may actually be measuring fibromyalgia pain. So we were kind of quite intrigued since we routinely use these tools in our clinical practice to assess disease activity to test whether they were really measuring fibromyalgia pain or not.

So we can hypothesize that these patient-reported outcome disease activity tools in AS, actually not only measure inflammatory pain, but were also measuring fibromyalgia pain and severity. So based on this hypothesis, we decided to test this in a proper study.

It was a cross-sectional prospective study. We prospectively enrolled 62 patients with ankylosing spondylitis from our arthritis clinic. In order to get included in the study, the patient should have been at least 18 years of age and had to fulfill New York classification criteria for ankylosing spondylitis and had to have grade 3 or grade 4 sacroiliitis. We wanted to make sure that the patients had established ankylosing spondylitis.

Then we administered these patient-reported outcome tools such as disease activity to these patients. We also measured their ESR and CRP, which are routinely used to assess disease activity by rheumatologists. To measure the frequency of fibromyalgia in these patients, we based it on 2010 ACR diagnostic criteria for fibromyalgia and asked the patients to record their widespread pain index scores and symptom severity scores.

The Study Results

So the results of the study were quite surprising. So we found about 27 out of the 62 patients fulfilled the 2010 diagnostic criteria for fibromyalgia, the ACR diagnostic criteria for fibromyalgia. So the estimated prevalence based on this was pretty high. It was much higher than we had seen in … has been seen in previous studies.

The two groups of patients with fibromyalgia and without fibromyalgia were not much different, at least in terms of age. The median age was about 49 years, and there was no difference in gender. There was no difference in use of biologics between the two groups. The only significant difference that we found between the two groups was that African Americans were more likely to have fibromyalgia compared to Caucasians.

Our main aim of the study was to test the relationship between BASDAI and ASDAS scores with that of widespread pain index and symptom severity scores using logistic regression analysis. We did not find any significant association between these two scores. We did not even find any association between ESR and CRP and widespread pain index and symptom severity scores, so we were unable to prove our hypothesis.

We do acknowledge some limitations of the study. The limitations are that, firstly, it was a small cohort of patients. Another, that our patients who were included in the study had very high disease activity index and which may have caused some kind of bias. Hence, the prevalence … estimated prevalence of fibromyalgia, which we detected, was very high.

So to … for practical purposes, the study helped us 1) that those patients with ankylosing spondylitis with a very high disease activity scores, the clinicians should look for fibromyalgia symptoms in these patients because we found those patients who had very high disease activity scores tend to have more fibromyalgia than patients whose disease activity scores were low. And there’s a plausible explanation for that, because these are the patients who are in pain, and when they’re in pain, they may not be sleeping well. They may not be able to do enough physical activity.

Another thing is that we found that both BASDAI and ASDAS are useful, reliable tools of disease activity in AS, hence, should be routinely used in the clinical practice to gauge treatment.

Gota: Fibromyalgia is a biopsychosocial disorder and it can be associated with a lot of other medical conditions. Patients with fibromyalgia have widespread pain, have nocturnal pain, have a lot of morning stiffness, have fatigue, and a lot of other symptoms like neurological symptoms, neurologic type pain, difficulty with memory and concentration, and oftentimes they have associated depression and anxiety or other mood disorders.

The symptoms of autoimmune disorders and other inflammatory diseases can also be those of chronic pain. They can also be associated with nocturnal pain, morning stiffness, and fatigue. The presence of pain can affect how people will sleep. So sometimes for the clinician it’s difficult to differentiate which one is the reason for the patient’s complaints.

If you look at people with chronic conditions, for instance rheumatoid arthritis, about 20% of those patients probably have fibromyalgia. The percentage depends on the study and the way fibromyalgia was assessed. If you look at the literature in ankylosing spondylitis or psoriatic arthritis — the seronegative spondyloarthropathies — it’s about 15%, but there’s one study that shows a higher percentage. This was a study of ankylosing spondylitis in females, and they reported about 50% of those patients also had fibromyalgia. So in patients with chronic illnesses the prevalence of fibromyalgia is higher. We believe that’s happening at least partially because these are chronic stressors.

Diagnosing Fibromyalgia

You can diagnose fibromyalgia in several ways. The most important thing is by discussion with the patient. At the time of the clinical encounter when you listen to the patient, how the patient describes the pain and the associated symptoms, you get a sense that the fibromyalgia may be an issue. The most important aspects that make you think somebody has fibromyalgia are as follows. One, the pain is going on for a long period of time. Also the pain is generally widespread. It affects the back, the upper extremities, lower extremities, sometimes chest, abdomen. And there are features of the pain that are very suggestive of fibromyalgia. The pain occurs with rest. It’s worse after exertion but has some degree of improvement with activity.

It’s also strongly associated … when the patients describe the pain they use a lot of color. They describe it oftentimes in dramatic terms — stabbing, burning, unbearable, and often they use what we call neuropathic characteristics for the pain. So patients will say it’s burning, tingling, which is a little different from other conditions like rheumatoid arthritis where these kinds of neuropathic aspects are missing.

Also the pain is almost always associated with fatigue. These patients have a lot of fatigue, they have nonrestorative sleep, and they also describe, which untrained clinicians are not aware of, a lot of stiffness. In our patient population at the Cleveland Clinic, we found that about 60% of patients with fibromyalgia reported morning stiffness of more than an hour. So that can sometimes be confusing because we usually associate morning stiffness with inflammatory conditions.

This Study’s Findings

Well their results are surprising if you look at several other papers. There is one recently that was published in September from France, where they looked at patients with ankylosing spondylitis, they looked at patients with psoriatic arthritis, and the prevalence was about 15% of comorbidity between fibromyalgia and spondyloarthropathy. I don’t know why this study found such a high prevalence. It is well known that women who have ankylosing spondylitis have a higher prevalence of fibromyalgia than men with ankylosing spondylitis, but that was not what this study showed. This was just an abstract that was published and we are awaiting the more detailed publication about how the patients were recruited.

From what I read in the abstract, the criteria for fibromyalgia were the American College of Rheumatology 2010 criteria. If you look at these criteria, it’s composed of two subsets. One is the widespread pain index. That measures pain in different body parts. They’re supposed to be nonarticular but sometimes patients cannot make that differentiation. And the areas involve the upper neck, upper back, lower back, upper extremities, lower extremities, and those are also areas that hurt in ankylosing spondylitis. The other part of the American College of Rheumatology criteria includes the symptom severity score and that has four questions that grade the severity of fatigue, the severity of cognitive problems, the difficulty with sleep, and then a set of other somatic symptoms.

You can see that fatigue can occur in both patients with ankylosing spondylitis but also in fibromyalgia. A lot of the pain in ankylosing spondylitis is nocturnal so it’s imaginable that a lot of these patients don’t sleep well even if they do not have fibromyalgia. So my personal opinion, what I think in this study, is that probably the American College of Rheumatology 2010 criteria for fibromyalgia may be difficult to apply as a diagnostic tool for fibromyalgia in this subset of patients with ankylosing spondylitis because of the similarity of symptoms. So I’m not sure that these criteria correctly identify patients with fibromyalgia.

If you look at the data, patients who had ankylosing spondylitis and fibromyalgia also had higher C-reactive protein and higher sedimentation rates than the ones who didn’t, which is hard to interpret and definitely cannot be attributed to fibromyalgia. And if you look at prior studies, what they found was that actually using the CRP as a measure of disease activity was helpful in differentiating ankylosing spondylitis from fibromyalgia.

Contextual Factors

There was a very nice editorial in the Journal of Rheumatology that was associated with the article I mentioned previously from France looking at the prevalence of fibromyalgia and spondyloarthropathy. They used the term ‘contextual factors.’ So you always have to look at the whole patient. Fibromyalgia patients usually have pain for a long time, but they don’t only have pain. They also have a lot of other issues. They usually have a lot of stress in their lives. A lot of these patients have prior traumatic events. A lot of patients endure depressive symptoms, they do not sleep well, they report a lot of stiffness.

It’s very important when we consider fibromyalgia to take into consideration other factors that we may call contextual factors. Patients with fibromyalgia oftentimes have a lot of stress, their symptoms have been going on for a long time, they have disturbed sleep, and they often endure depressive and anxiety symptoms. And they have other manifestations such as symptoms of irritable bowel syndrome, migraine, which can be very helpful in understanding that this is probably fibromyalgia.

I think that patients who have both fibromyalgia and ankylosing spondylitis or other inflammatory diseases can pose a challenge for the clinician. I think the most important thing is to take a good history, listen carefully to the patient, do a complete physical examination, and oftentimes that is very helpful in differentiating the two or being able to recognize that there is more than one mechanism at play.




How Do You Deal With Hair-Pulling And Skin-Picking Compulsions?

Dealing with a body-focused repetitive behavior (BFRB) like compulsive hair-pulling or skin-picking can be exhausting and frustrating, to say the least.


“Body-focused repetitive behavior” (BFRB) is a general term for any disorder that makes someone touch their hair and body in ways that result in physical damage — like bald patches, skin discoloration, bleeding, or scarring. Trichotillomania (hair-pulling disorder) and excoriation (skin-picking disorder) are two common BFRBs.

And while working with a professional is the best way to move toward recovery, lots of people have found little ways to keep picking and pulling compulsions at bay day-to-day.

So we want to know: Outside of professional treatment, what things have been invaluable in dealing with your pulling or picking compulsions?

Maybe you keep track of every day you go without pulling or picking and reward yourself after a streak.

Maybe you keep track of every day you go without pulling or picking and reward yourself after a streak.

@_anymalinka_ / Via instagram.com

Or maybe you rely on fiddle jewelry to keep your fingers busy.

Or maybe you rely on fiddle jewelry to keep your fingers busy.

FullMoonJewellery / Via etsy.com

Maybe you keep a collection of fabric scraps handy to destroy when you really need to pick or pull.

Maybe you keep a collection of fabric scraps handy to destroy when you really need to pick or pull.

@justchaseit / Via instagram.com

Or maybe you’ve discovered ways to camouflage the effects to help reduce anxiety during recovery.

Or maybe you've discovered ways to camouflage the effects to help reduce anxiety during recovery.
Kaylann Marie / Via youtube.com

Like, maybe finally learning how to get a great brow look with makeup was really empowering — and helped you keep your hands off.



‘ COPD kills one person every 10 seconds ’

“The COPD kills an average one person every 10 seconds and the death rate from COPD is increased about 10-fold for each 15 cigarettes smoked daily and regularly in the past,” it was revealed in a press briefing to mark COPD awareness month in Pakistan here on Wednesday.

Dr Ashraf Jamal, President Pakistan Chest Society (Punjab), and Pulmonology Department head at Jinnah Hospital Lahore said that according to WHO estimates for 2030, COPD is predicted to become the third leading cause of death killing over 4.5 million people worldwide. He added, ’it has been proved scientifically that smoking cigarettes from adolescence to adulthood costs on average 10 years of life.’

He said “In Pakistan, 18.7 percent smoking rate and breathlessness alone is the most frequently reported symptom of COPD. It is known that almost 90 percent of COPD deaths occur in low and middle-income countries and cigarette smoking is the most commonly encountered risk factor for COPD.” ‘It is estimated by WHO that close to 210 million cases of COPD could possibly be found worldwide, while some estimates put this number as high as 400-600 million. By 2015, COPD had been killing more than three million people worldwide every year (that is 5 percent of all deaths globally in that year),’ he added.

He added that many cases of COPD were preventable by avoidance or early cessation of smoking, hence it is important that countries should adopt the WHO Framework Convention on Tobacco Control (WHO-FCTC) and implement the MPOWER package of measures so that non-smoking becomes the norm globally. Measures of WHO stresses monitoring of tobacco use and its prevention policies, protecting people from tobacco smoke, offering help to quit tobacco use, warning about the dangers of tobacco, enforcing ban on tobacco advertising/ promotion/ sponsorship and raising taxes on tobacco.

‘Dr Kamran Khalid Chima, Pulmonology Department head, Services Hospital Lahore said, ‘Chronic obstructive pulmonary disease (COPD) develops slowly and usually becomes apparent after 40 or 50 years of age.

COPD is not curable, but treatment can relieve symptoms, improve quality of life and reduce the risk of death,’ he added. Moreover, he said COPD is one of the most common respiratory disorders worldwide as 65 million people have moderate to severe
COPD. “In Pakistan, the prevalence rate of COPD related symptoms is 18.5 percent and COPD patients with co–morbidity are 26.7 percent.


Man drinking water with lemon

Drinking Lemon Water Every Morning Like This – A Mistake Millions Of People Make

We all know how many people often make a characteristic face when they eat lemons. You know the tight, puckered lips and squinted eyes.

You probably think that lemon has the best effect when it’s eaten raw, but actually if you combine lemon juice with a glass of hot water and drink it in the morning, can have some amazing benefits for your overall health, too.

Is Lemon Water Good For You?

One positive thing is that you won’t make that odd face like you do when you eat a raw lemon! Hot lemon water in the morning is incredibly refreshing, invigorating and it gives your metabolism the much needed boost.

Lemons are loaded with healthy benefits, and they’re a particularly great source of vitamin C.

One cup of fresh lemon juice provides 187 % of your recommended daily serving of vitamin C!

Lemon juice also offers you a healthy serving of potassium, magnesium and copper.

Still, you must pay attention of how you serve and drink lemon water. There is one common mistake that most people make when they’re enjoying a glass of lemon water. The lemon peel is one of the most nutritious parts of the whole fruit.

Your normal routine would probably be: slicing the lemon, squeezing the juice into a bottle and adding some hot or ice water. This is actually the wrong way.

Luckily for you, that’s why we’re here today! Here’s the right way to prepare lemon water!

The Ideal Lemon Water Recipe

-Take out a couple of fresh, preferably organic lemons.
-Slice them as thin or thick as you like.
-Squeeze some of the sliced lemons into the water but not all.
-Grate some of the zest of these squeezed slices into your drink.
-Place the remaining un-squeezed slices in your blender bottle, mug, or travel cup.
-Fill to the brim with either boiling hot, or ice cold water.

Lemon Water For The Win

According to many health experts, lemon water’s acidity helps in the process of digestion. It also helps to slow absorption of food, which conserves insulin stores in the body and ensures your body gets the most out of the food it’s processing.

Lemon water can also give your GI tract the push it needs in the morning to get things moving and also reduce fluid retention.

So, why don’t you try it out today? Prepare it the right way and enjoy all its benefits!

Source: healthylifetricks.com

LAS VEGAS, NV - SEPTEMBER 30:  Singer/drummer Dan Reynolds of Imagine Dragons performs during the third annual Tyler Robinson Foundation gala benefiting families affected by pediatric cancer at Caesars Palace on September 30, 2016 in Las Vegas, Nevada.  (Photo by Ethan Miller/Getty Images)

My Hidden Disease: I Have Ankylosing Spondylitis And I’m Not Alone

Empathy, sadness, joy and a sense of family are just some of the immediate feelings I had when I ended my FaceTime conversation with Dan Reynolds, lead singer of Imagine Dragons.

Dan and I have something in common called ankylosing spondylitis, or AS for short. Instead of getting into a long, drawn-out medical definition, I will describe it like this: our bodies are attacking themselves, and there is no cure.

People suffer in silence and feel they are alone because they think no one understands.

Most of us AS sufferers have to deal with chronic pain 24/7. It is a “hidden disease,” as Dan labelled it. Dan is a now a spokesperson for our disease through an awareness campaign launched in collaboration between the Spondylitis Association of America (SAA) and Novartis Pharmaceuticals (U.S.). They provided me this amazing opportunity to speak with Dan, not on a musician/star basis, but on a personal one.

Dan and I were diagnosed with AS almost at the same time. When I was listening to him speak, I began to feel an immediate connection. Dan knew he had AS for almost a decade before announcing it to tens of thousands in First Direct Arena in Leeds, England on Nov. 10, 2015.

“I didn’t want the world to know for fear it would be a weakness… I don’t really know honestly why (I shared my AS on stage), but I don’t regret it,” he told me.

This statement resonated so much with me. For some reason in this world, no one is allowed to show vulnerability even if they’re ill. People with a lot of different diseases suffer in silence and feel they are alone because they think no one understands.

I have a disease that no one can see. AS can affect every joint in your body, your internal organs and your mental health. I unfortunately know people who have ended their lives. They just couldn’t take their AS struggle anymore.

People who suffer from AS tend to become family, whether they want to or not.

I am amazed at the way Dan looks at AS. He is so full of positivity and wants to be a voice for all of us that have it. I alone couldn’t think of a better spokesperson for us “AS Warriors,” as we like to call ourselves.

People who suffer from AS tend to become family, whether they want to or not. We are the only ones who truly understand what we are going through — from restless nights, to being too sore to leave the house, to missing out on fun activities with friends.

dan reynolds
Dan Reynolds of Imagine Dragons on Sept. 30, 2016 in Las Vegas, Nevada. (Photo: Ethan Miller/Getty Images)

Dan was very adamant and wanted people to know “you aren’t alone, there is a community out there.”

I can’t stress this point enough. We have both felt alone, even with family around. It isn’t the same trying to explain what you are going through to someone who isn’t dealing with AS. Dan emphasized, “You need to find comfort in other people’s stories… now I really want to do all I can, to be a voice for it and to spread awareness so people don’t feel so alone.”

Dan accepts that as a spokesperson, people like me may now approach him for advice. “I hope people go to their rheumatologists and not to Doctor Dan, ’cause I got nothing,” he quipped. But my lasting impression of Dan is that in life lessons, he knows a great deal. Throughout his struggle with AS, Dan speaks about how very supportive his wife is and how even his four-year-old daughter knows how to pronounce ankylosing spondylitis.

dawn hamilton as
Dawn Hamilton lives in St. Catharines, Ontario and was diagnosed with AS in 2008.

I was excited to learn the Imagine Dragons may be going on tour in 2017. I can’t wait to see the tour list. Dan mentioned that AS had “fed the creative part” of him when it came to music, and it gave him “passion to create more music.”

AS affects every part of our life. As a creative musician, Dan’s lyrics, music and even performance are directly impacted by AS.

“Emotion is what breeds art and I definitely had emotions, someone telling you, you have a disease that could possibly ruin your life,” he said. When you have a chronic ailment, your emotions tend to be all over the place — and sometimes you take it out on the people you are closest to.

Although I only spoke with Dan for minutes, I feel like I’ve made a life-long friend.

Our discussion wasn’t all serious, though. When I asked if he would ever write a song about AS, he immediately burst into song. “I think it has already been fused into many songs whether I knew it or not,” he said. I now think it is time for me to listen a bit closer to the lyrics of Imagine Dragons and see what I can hear.

Although I only spoke with Dan for minutes, I feel like I’ve made a life-long friend. I will probably never be able to talk to Dan again, but I know he’s out there rooting for all of us. And now, we’re all inspired by his music, his courage and his life with AS.




Uveitis in Ankylosing Spondylitis : Risk Factors Identified

Uveitis should be suspected in patients with ankylosing spondylitis (AS) who have high lesion counts, antistreptolysin O (ASO) and circulating immune complex (CIC) titers, according to retrospective research presented at the 2016 ACR/ARHP Annual Meeting.

“This study provides some evidence that hip-joint lesion, the number of peripheral arthritis, ASO and CIC may be associated with higher rates of uveitis in AS,” reported Feng Wang, MD, of the Nephrology and Rheumatology Department, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital in Shanghai, China. “The results of this comprehensive analysis suggest that the possible occurrence of uveitis in AS should not be neglected in patients who have those concomitant risk factors.”

The authors enrolled 390 patients with AS and ophthalmologist-diagnosed uveitis (80.5% male; mean age 33.3 years), between January and December 2015. Disease duration, HLA-B27, and peripheral hip-joint lesion counts were retrieved from medical records and imaging exams, and biochemical function labs were conducted.

Thirty-eight (9.7%) patients experienced at least one uveitis episode, and hip-joint lesions occurred at a higher incidence rate among these patients than those with no history of uveitis, the authors reported (44.7% vs. 22.2%; P<0.01). Patients in the uveitis-history study group also had higher peripheral arthritic lesion counts (2.18±0.23 vs. 0.55±0.04; OR, 4.1; 95%CI: 2.6-6.3; P<0.01), ASO (odds ratio [OR], 12.2; 95% CI:3.6-41.3; P<0.01), and CIC (P<0.0001).

“However, there were no significant differences in disease duration, HLA-B27, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) between the two groups,” the researchers found.



Fine-Tuning Treatment for Ankylosing Spondylitis

Less than a year ago, the American College of Rheumatology in conjunction with other groups such as the Spondyloarthritis Research and Treatment Network published recommendations for the treatment of ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA), but there have been new developments since then, and likely even more to come.

In the recommendations, the authors stated: “The goals of treatment of AS and nonradiographic axial SpA are to reduce symptoms, maintain spinal flexibility and normal posture, reduce functional limitations, maintain work ability, and decrease disease complications.”

In an interview with MedPage Today, the lead author, Michael M. Ward, MD, chief of the Clinical Trials and Outcomes Branch of the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda, Md., added: “In my opinion, the most important aspect of the recommendations is that they focus on providing recommendations for treatment decisions for specific clinical situations, based on the type of patient and the treatment history.

“For example, the recommendations address what treatment should be considered for a patient with active AS who has not responded to the first tumor necrosis factor [TNF] inhibitor used. This approach, using common clinical situations, makes the recommendations directly applicable to practice.”

The 2015 Recommendations

The recommendations were based on a systematic literature review through 2014, formulation of clinical questions to be addressed, and reviewing and rating the evidence. The authors cautioned that the guidelines are meant to apply to typical patients, rather than exceptional cases, and that treatment decisions should always involve education of the patient regarding anticipated benefits and potential harms.

Regarding the various categories of recommendations as stated in the document, strong recommendations were those that would be agreed to by “almost all informed patients,” while conditional recommendations were those that would be chosen by most informed patients, although a minority would not. Recommendations that are conditionally against the treatment are those that would not be chosen by most informed patients, and those that were strongly against, should not be used.

The recommendations initially addressed pharmacologic treatment of patients with active AS, with a strong recommendation for the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and a conditional recommendation in favor of continuous rather than on-demand use. No particular NSAID was specified as preferable. Rather, “choice of NSAID should be based on consideration of the patient’s past history of NSAID use, risk factors for adverse effects, and co-morbidities.”

The authors also strongly recommended using TNF inhibitors for patients who had a lack of response or intolerance to at least two NSAIDs. Overall, the guidelines did not favor any specific TNF inhibitor, although they noted that infliximab (Remicade) or adalimumab (Humira) would be preferable for patients who also have inflammatory bowel disease or recurrent iritis.

For patients whose AS remained active despite treatment with a TNF inhibitor, the conditional recommendation is for using a different TNF inhibitor, because of insufficient data at the time of writing the document to support the use of the available non-TNF biologic agents.

The guidelines strongly recommended against the use of systemic glucocorticoids in active AS, although a short course with rapid tapering might be useful in circumstances such as a flare of accompanying peripheral arthritis. Local injections of glucocorticoids could be given to patients with enthesitis or active peripheral arthritis.

For patients with stable AS, which was defined as “asymptomatic or causing symptoms that were bothersome but at an acceptable level as reported by the patient” for at least 6 months, the authors conditionally recommended on-demand rather than continuous NSAID use. In addition, for patients with stable AS being treated with NSAIDs plus TNF inhibitors, there was a conditional recommendation for ongoing treatment with the anti-TNF agent alone.

Other aspects of the recommendations included treatment with physical therapy (strong recommendation) and back exercises (conditional recommendation), as well as total hip arthroplasty for those with advanced arthritis of the hip (strong recommendation).

For patients with nonradiographic axial SpA, the document noted that the literature was sparse and so advised that the same approach should be used as for AS, with the exception of a conditional rather than a strong recommendation favoring the use of TNF inhibitors for NSAID nonresponders.

After the Guidelines

The approval of the interleukin-17A inhibitor secukinumab (Cosentyx) for AS shortly after the publication of the recommendations broadened the treatment options, but as yet there has been little guidance as to where in the treatment paradigm this agent will fit.

When the panel was considering the treatment options, the full paper reporting on the two double-blind MEASURE studies of secukinumab had not yet been published. “The guidelines were excellent, but they quickly became obsolete by the time they were in print,” commented one of the coauthors, Atul Deodhar, MD, of Oregon Health & Science University in Portland.

The availability of secukinumab has increased the focus on the question of what should be done if a patient fails on a first TNF inhibitor, he told MedPage Today. “What we don’t know is whether we should try another anti-TNF or change to secukinumab. No such study has been done to compare.”

Switching to another TNF inhibitor can work, but there is no good evidence as yet whether changing to secukinumab would be more effective, Deodhar noted. “The usual expert opinion would be to try at least two TNF inhibitors before changing.”

It is also important to consider whether the patient experienced primary or secondary failure to TNF inhibition. “Primary failure would be if you give etanercept [Enbrel] and they have absolutely no response, whereas usually with secondary failure, the patient initially says ‘Wow, this is fantastic,’ but after a year or two it’s not working so well. These are the people who do respond to a second TNF inhibitor. With primary failure, I would try secukinumab,” Deodhar said.

There also are other potential agents in development for AS, such as the interleukin-12/23 blocker ustekinumab (Stelara), which is approved for Crohn’s disease and is currently in clinical trials for AS, and the JAK inhibitor tofacitinib (Xeljanz). “And I’m sure the other companies that are making JAK inhibitors will be in this space very quickly,” he said.

Ward said that discussions have begun to update the recommendations to incorporate new evidence since the last literature review and include newly approved medications — “But this work has not yet begun.”




Opioids for Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a chronic condition that affects the joints of the spine and pelvis. The joints may become stiff or fixed due to ligaments adhering one bone to another. AS has symptoms similar to that of rheumatoid arthritis. Medication and exercise have been used to help slow the progression of the disease, but advanced stages of AS can be excruciatingly painful. Opioids, or narcotics, are often prescribed when the pain of AS becomes so severe that it interferes with daily activities.


Vicodin is an opioid/narcotic painkiller. It is a combination of acetaminophen and hydrocodone. Vicodin is prescribed in tablet form and is used to treat moderate to severe pain. Acetaminophen is added to hydrocodone to increase its potency.
The hydrocodone in Vicodin can be habit forming. Only the person for whom it has been prescribed should use it. Vicodin may be prescribed in the early stages of ankylosing spondylitis. As the stiffening of the joints progresses, stronger forms of pain relievers may be needed. Vicodin may cause side effects such as drowsiness, lightheadedness, vomiting, headaches and dizziness.


Oxycodone, an opioid/narcotic pain reliever, can only be obtained through a prescription, and a physician should monitor its use. Oxycodone may be obtained in an extended-release form that works around the clock to control pain. Oxycodone is prescribed for patients with ankylosing spondylitis because it has the ability to control pain for several hours without repeating the dosage every few hours. Oxycodone is similar to morphine in its effectiveness. As with other narcotics and opioids, oxycodone carries the risk of becoming habit forming. Oxycodone can have serious side effects including seizure, confusion, headache, dizziness and nausea.


Morphine is a very potent opioid/narcotic painkiller. It may be obtained in tablet form or intravenously while in the hospital. Morphine may not be prescribed unless a person has had prior treatment with other opioid painkillers. Morphine can be obtained for short-term pain relief, or as an extended-release pain reliever. Morphine works by dulling the part of the brain that experiences the perception of pain. According to Drugs.com, morphine is highly addictive and should only be used under the close supervision of a physician.


Number of patients suffering from hemophilia in the world increases


Head of the Health Ministry’s Scientific-Practical Center of Hemophilia Elmira Gadimova said that 65 patients were registered in the 10 months of this year, APA reports.


Gadimova noted that the number of medicines bought for patients suffering from hemophilia have increased twice in the last ten years. “This year, 23 million of medicines were brought for patients suffering from hemophilia, while this figure was 12 million in 2006. The patients with hemophilia receive outpatient and stationary treatment”, she said.


The head of the center noted that the number of the patients with hemophilia is higher in Baku and Sumgayit cities, and the central lowland districts. According to her, 736 patients with hemophilia are registered in Baku, while 77 others were registered in Sumgayit.