Symposium Article
Management of Comorbidities in Ankylosing Spondylitis

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Abstract

The major comorbidities of ankylosing spondylitis include uveitis, bowel inflammation, psoriasis and heart disease. The pathogenic mechanism to account for the coexistence of comorbidities remains largely unknown. In some instances, the comorbidity has a major impact on the choice of therapy.

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WHAT IS KNOWN FROM EXISTING LITERATURE AND GUIDELINES?

Comorbidities associated with AS include diseases or manifestations involving the skin, eye, bone, gastrointestinal (GI) and genitourinary tracts and the cardiorespiratory, renal and neurological systems. In the interest of time, uveitis, inflammatory bowel disease (IBD), atherosclerotic cardiovascular disease and osteoporosis were discussed.

Observational studies have long reported the association between comorbidities and AS. Comorbidities such as psoriasis, IBD and uveitis have

UVEITIS

Recurrent acute anterior uveitis (AAU) is a common comorbidity associated with AS. Topically applied corticosteroid drops combined with mydriatic agents such as scopolamine are usually sufficient for treating acute episodes. Topical steroids are less effective for posterior inflammation. For more severe cases, periocular steroid injections may be required. Persistent uveitis, which is relatively rare in association with AS, may be treated with immunosuppressive agents such as methotrexate,

INFLAMMATORY BOWEL DISEASE

The prevalence of clinically overt IBD in patients with AS is 5% to 10%. On ileocolonoscopy, evidence of IBD is seen in 25% to 49% of patients. Histopathological studies show evidence of IBD in 50% to 60% of patients with AS.3 The presence of IBD has implications in the management of AS. Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) has the potential to reactivate underlying IBD. The rates of hospital admission for flare and new onset IBD colitis were increased with both current

CARDIOVASCULAR DISEASE

There is a paucity of information on cardiovascular risk in patients with AS. Recently, a systematic review and meta-analysis of studies available through August 2009 was published.7 Patients with AS had a significantly increased risk of metabolic syndrome and a higher weighted mean carotid intima to media thickness compared with controls. There was a trend toward increased risk for MI. One study reported that AS increases stroke risk compared with controls. A recent questionnaire-based study

OSTEOPOROSIS

AS is associated with bone loss in the vertebrae and an increased prevalence of vertebral fractures. The literature about the magnitude of fracture risk is limited. A large primary care-based, nested, case-control study showed that patients with AS have an increased risk of clinical vertebral fracture (odds ratio [OR], 3.26).9 The risk of any fracture increased with concomitant IBD (OR, 2.79) but decreased with NSAID use (OR, 0.65).

AVAILABLE GUIDELINES ON THE MANAGEMENT OF COMORBIDITIES IN AS

Available guidelines on the management of AS were reviewed to identify specific recommendations for the management of comorbidities in the context of AS. None specifically addressed the issue of comorbidity. The Canadian Rheumatology Association/Spondyloarthritis Research Consortium of Canada treatment recommendations for the management of spondyloarthritis (SpA) recommend that treatment of SpA should be tailored according to extra-articular symptoms and signs and comorbidity.10 The

WHAT WE DO NOT KNOW ABOUT COMORBIDITIES ASSOCIATED WITH AS?

First as clinicians and scientists, we need to acknowledge that we may not be aware of all the comorbidities that are associated with AS. For example, the recognition of atherosclerosis as a comorbidity of RA and systemic lupus is relatively recent. As the treatment of a disease evolves and as new technologies allow us to understand a disease in new ways, previously unappreciated aspects of an illness can emerge. Without colonoscopy, we could not have recognized the frequency of occult IBD

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Presented at the annual research and education meeting of Spondyloarthritis Research and Treatment Network (SPARTAN), Portland, Oregon, July 29–30, 2011.

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