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The Many Faces of Ankylosing Spondylitis: Evidence-Based Approach to


Diagnosis and Management CME/CE

Complete author affiliations and disclosures are at the end of this activity.

Release Date: May 27, 2008; Valid for credit through May 27, 2009

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This activity is intended for rheumatologists, primary care physicians, and nurses.

Goal

The goal of this activity is to educate physicians to recognize patients with early-stage ankylosing spondylitis, to make a correct
differential diagnosis, and to initiate appropriate management strategies.

Learning Objectives

Upon completion of this activity, participants will be able to:

1. Identify the presentations of ankylosing spondylitis (AS), including nonjoint manifestations


2. Recognize the importance of early diagnosis and aggressive management of both joint and nonjoint manifestations of AS
3. Review the existing guidelines for treatment of AS
4. Discuss the criteria for classification of probable and definite AS
5. Evaluate recent data and assess the potential role of newer therapies, such as antitumor necrosis factor-alpha, in the
long-term management of AS and its extra-articular manifestations

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Contents of This CME/CE Activity

The Many Faces of Ankylosing Spondylitis: Evidence-Based Approach to Diagnosis and Management
Muhammad A. Khan, MD, FRCP, MACP; Mazen Elyan, MD

The Many Faces of Ankylosing Spondylitis: Evidence-Based Approach to Diagnosis and Management

The following test-and-teach case is an educational program modeled on the interactive grand rounds approach. The questions are designed to
test your current knowledge. After each question, you will be able to see whether you answered the question correctly. The author will then
present referenced information to support the most appropriate answer choice. Please note that these questions are designed to challenge you,
and you are not penalized for answering the questions incorrectly.

Patient History and Introduction

Adam is a 26-year-old architect who was referred by his primary care physician (PCP) for chronic low
back pain. He first presented to his PCP 8 months ago with subtle onset of dull buttock pain alternating from
side to side. Four months later he developed chronic low back pain and stiffness that frequently awakens
him late at night or early in the morning. These symptoms are relieved to a large extent with a hot shower
and physical exercise, but worsen after sitting in a chair for more than 2 hours. These symptoms are
progressively affecting his quality of life.

Adam has taken diclofenac 75 mg twice daily for 1 month without significant relief of his symptoms, and
subsequently tried naproxen 500 mg twice daily for another month with moderate relief. He reports having
had 3 acute episodes of eye pain and redness with blurry vision in the past 2 years; one episode involved his
right eye and 2 episodes involved his left eye. All 3 episodes were treated with steroid eyedrops. X-ray of
the pelvis anteroposterior view revealed no definite evidence of sacroiliitis. Laboratory testing by the PCP
revealed an elevated C-reactive protein (CRP) level of 3 mg/dL and an erythrocyte sedimentation rate
(ESR) of 52. HLA-B27 test was positive. He has tenderness over spinal processes of the lumbar spine, and
over the sacroiliac joints. On exam he walks with a slightly stiff gait.

Which of the following is least likely to be found in this patient?


Occiput-to-wall distance of 0 cm
Modified Schober's test showing a distance increase from 10 cm to 15 cm

Chest expansion less than 2 cm at the level of the xiphisternum


Chest pain that worsens with inspiration and cough
Heel pain

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The entheses, the sites of bony insertion of ligaments and tendons, are among the major affected sites in AS. The entheses are present
throughout the body, including the sacroiliac joints, spinal processes, heels, iliac crest, anterior chest wall, and other bony prominences.
Enthesitis presents as pain and localized tenderness in these areas. Enthesitis of the chest wall and arthritis of the costovertebral and
costotransverse joints may result in chest pain that increases with inspiration and cough, a clinical picture that may be confused with pleurisy.
Localized chest wall tenderness typical of enthesitis of the chest wall in AS helps to differentiate it from pleuritic chest pain.[1] Measures of
spinal mobility in AS are shown in Table 1.

Table 1. Measures of Spinal Mobility in Ankylosing Spondylitis[2]

Measure* Description
Cervical rotation
Measure the angle of the cervical rotation with a goniometer.

Another method is to measure with a tape measure the distance between the tip of the nose and the
acromioclavicular joint at baseline (when the neck is in neutral position) and on maximal ipsilateral rotation. A
smaller difference indicates a more restricted cervical rotation. The difference between these 2 positions
measures the rotation and is measured separately for right/left and left/right rotations.

Fingertip-to-floor
distance Distance between tip of right middle finger and the floor following maximal lumbar flexion while maintaining full
extension of the knee, measured ideally with a rigid tape measure. Smaller distance indicates greater
movement.

Lumbar lateral
flexion Distance between tip of ipsilateral middle finger and floor following maximal lateral lumbar flexion while
maintaining heel contact with floor, full extension of the knees, and without rotation of the trunk. This can be
better achieved if the patient stands with the back against a wall. It should be measured ideally with a rigid tape
measure. A smaller distance indicates greater movement.

Domjan method (modified): A mark is placed on the skin of the patient's one leg at the tip of the ipsilateral
middle finger on maximal lateral lumbar flexion to that side, and another mark is placed on the same leg at the
fingertip on maximal lateral lumbar flexion to the contralateral side. The distance between those 2 marks placed
on 1 leg during the above-mentioned 2 maneuvers reflects lateral flexion of the lumbar spine.

Modified
Schober's index Distance between 2 marks placed 10 cm apart on the lumbar spine in the midline, with the patient standing
upright; the lower mark is at the level of the dimples of Venus or the posterior superior iliac spines. The distance
between these 2 marks is measured again while the patient is maximally forward-flexing the spine, with the
knees fully extended. Normally there is an increase of at least 5 cm, ie, the distance between the 2 marks
reaches 15 cm. An expansion of less than 4 cm indicates reduced mobility of the lumbar spine.

Tragus-to-wall
distance When the subject is standing erect with heels and buttocks against the wall (to prevent pivoting), knees fully
extended and chin drawn in to keep a horizontal gaze, horizontal distance is measured with a rigid tape measure
between the wall and the tragus of the right ear. Larger distance indicates worse forward stooping of the neck.

Occipital-to-wall
distance When the subject is standing erect with heels and buttocks against the wall (to prevent pivoting), knees fully
extended and chin drawn in to keep a horizontal gaze, horizontal distance is measured between the wall and the
posterior convexity of the occiput. Subjects with normal posture show no gap. Larger distance indicates worse
forward stooping of the neck.

*All measurements should be recorded after having the patient practice once.

Skeletal and Extraskeletal Manifestations of AS

Of the following joints, which are least likely to be involved in AS?


The hip joints
The proximal interphalangeal joints
The spinal facet joints

The discovertebral joints


The costotransverse joints

The association of the following extraskeletal manifestations with AS has been well described except for:
Psoriasis
Inflammatory bowel disease
Uveitis

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Aortic incompetence
Pericarditis

AS can be associated with psoriasis, Crohn's disease, and ulcerative colitis; it can also be associated with uveitis and to a lesser extent aortic
incompetence. Enteric mucosal inflammation has been found in the terminal ileum and proximal colon on ileocolonoscopic studies in 26% to
69% of asymptomatic AS patients. Approximately 6% of these patients will develop inflammatory bowel disease, and among those with bowel
inflammation on biopsy that histologically appears to be "chronic," 15% to 25% will develop symptomatic Crohn's disease.

Acute anterior uveitis occurs in 25% to 40% of patients with AS. It is typically unilateral and often recurrent, can affect either eye, and is more
common among those AS patients who possess HLA-B27. It can result in visual impairment if not promptly and effectively treated.

Which of the following specialties may be needed to help manage complications directly related to AS?
Cardiothoracic surgery

Ophthalmology
Orthopaedic surgery
All of the above
Ophthalmology and orthopaedic surgery

Differential Diagnosis of AS

The following conditions can be differentiated from AS on the following basis except:
Spondylosis (degenerative disc disease): back pain worsens on physical activity but eases with rest
Diffuse idiopathic skeletal hyperostosis (DISH): presence of hyperostosis involving the anterior longitudinal ligament in elderly patients who
often do not give history of chronic inflammatory back pain
The synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome: often associated skin manifestation, more localized osteitis
lesions, and lack of association with HLA-B27
Osteitis condensans ilii: radiographic evidence of bone sclerosis on the iliac side and adjacent to the lower half of normal-appearing
sacroiliac joints; primarily in women
Osteitis deformans: patchy areas of bony sclerosis in the pelvis with an elevated serum acid phosphatase

Lumbar spondylosis is usually differentiated on the basis of clinical history of pain that is often localized to the lower back, tends to worsen on
physical activity, and is relieved with rest.

DISH is usually seen in the elderly and is characterized by hyperostosis affecting the anterior longitudinal ligament and skeletal attachments of
tendons and ligaments. The posture and spinal stiffness may resemble AS, and x-rays of the sacroiliac joints may show severe degenerative
and hyperostotic changes (joint space narrowing, subchondral bone sclerosis, and capsular ossification), which can be confused with the
sacroiliitis of AS. DISH is not associated with HLA-B27.[5]

SAPHO syndrome is an inflammatory condition that can cause spinal and/or sacroiliac joint changes resembling spondyloarthropathies.[6]
Although SAPHO syndrome is not associated with HLA-B27, its differentiation from AS also requires the presence of other clinical features,
especially skin lesions.

Osteitis condensans ilii is typically seen in young multiparous women, often symptomatic, and characterized by radiographic evidence of a
triangular area of dense sclerotic bone in the iliac bones of the pelvis adjacent to the lower half of the sacroiliac joints, which themselves are
normal. Osteitis condensans ilii is a self-limited condition with no association with HLA-B27 and no evidence to indicate that it is a form of
AS.[7]

A delay in the diagnosis of AS would probably lead to which one of the following?
No effect on response to treatment with tumor necrosis factor (TNF) inhibitors
Less response to treatment with TNF inhibitors, but only after the first 20 years
Less response to treatment with TNF inhibitors, but only after the first 10 years
Less response to treatment with TNF inhibitors, but only after the first 5 years

Less response to treatment with TNF inhibitors for each year of undiagnosed disease

Although TNF inhibitors have been shown to be efficacious in patients with active AS, it is unclear which parameters predict this response.
The study by Rudwaleit and colleagues,[8] summarized in Table 2, concluded that a shorter disease duration, younger age, and a lower Bath
AS Functional Index (BASFI) score are predictors of a major clinical response to TNF inhibitors in active AS. Raised CRP and a higher Bath
AS Disease Activity Index (BASDAI) score may also be valuable predictors, although these correlations need to be confirmed in further
studies.

Table 2. Prediction of Response: OR and 95% CI of BASDAI 50 Response; Results Are Shown for Univariate (Total Population
and for Each Drug Separately) and Multivariate (Total Population Only) Logistic Regression Analysis[8]

AS Functional Univariate Analysis OR (95% CI) Multivariate Analysis (B

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Status Measure Model) OR (95% CI)

Total Population P Infliximab (n P Etanercept (n P


(n = 99) Value = 69) Value = 30) Value Total Group (n = 99)
Disease duration* 0.93 (0.88-0.98) .003 0.95 .050 0.89 (0.80-0.99) .015 0.94 (0.89-0.99)
(0.89-1.00)

BASFI† 0.75 (0.60-0.93) .007 0.81 .088 0.47 (0.25-0.88) .004 0.54 (0.38-0.76)
(0.63-1.04)

CRP (mg/L)‡ 1.02 (1.001-1.04) .035 1.02 .066 1.04 (0.99-1.09) .12 1.02 (1.002-1.05)
(1.00-1.04)

BASDAI† 1.34 (0.96-1.87) .082 1.44 .061 1.03 (0.52-2.03) .93 2.26 (1.34-3.81)
(0.97-2.12)

AS = ankylosing spondylitis; OR = odds ratio; CI = confidence interval; BASFI = Bath AS Functional Index; BASDAI = Bath AS
Disease Activity Index; CRP = C-reactive protein
*OR refers to the risk of achieving a BASDAI 50 response per year of disease duration/age.
†OR refers to the risk per 1 grade on a 0-10 scale.
‡OR refers to the risk per 1-mg/L increase of CRP.

Clinical Criteria for AS Evaluation

Which of the following is correct concerning the modified New York criteria for AS?
The modified New York criteria for AS are the gold standard diagnostic criteria for AS
According to the modified New York criteria for AS, a patient is considered to have definite AS if all clinical criteria (inflammatory back pain,
limitation of mobility of the lumbar spine, and limitation of chest expansion) are met, even with radiographically normal sacroiliac joints
The modified New York criteria for AS are highly sensitive

The modified New York criteria for AS are not specific


None of the above

According to the modified New York criteria, a patient can be classified as having definite AS if at least 1 clinical criterion (inflammatory back
pain, limitation of mobility of the lumbar spine, or limitation of chest expansion) and the radiologic criteria are met (Table 3).[9] The
requirement for radiographic evidence of sacroiliitis results in low sensitivity for the AS criteria if applied to patients with early disease. This is
because the patients who present with clinical symptoms but without radiographic sacroiliitis will not be recognized as having AS.
Consequently, according to the modified New York criteria, a patient is considered to have probable (not definite) AS if all clinical criteria
(inflammatory back pain, limitation of mobility of the lumbar spine, and limitation of chest expansion) are met in the absence of radiographic
evidence of sacroiliitis.

Table 3. The Modified New York Classification Criteria for AS[9]

Clinical criteria

1. Low back pain and stiffness for > 3 months that improves with exercise but not with rest

2. Limitation of lumbar spine mobility in both the sagittal and frontal planes
3. Limitation in chest expansion compared with normal range for age and sex

Radiologic criteria
1. Unilateral sacroiliitis of grade 3-4; or

2. Bilateral sacroiliitis of grade ≥ 2

Grading
1. Definite AS if the radiologic criterion is associated with at least 1 clinical criterion

2. Probable AS if:

3 clinical criteria are present or


The radiologic criterion is present without any signs or symptoms satisfying the clinical criteria

AS = ankylosing spondylitis

Which of the following is essential for a laboratory evaluation for AS?


Normal CRP rules out active disease in patients with AS
CRP and ESR have no value in evaluating patients with AS

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HLA-B27 is a useful screening test


Normal CRP rules out active disease in patients with AS, and HLA-B27 is a useful screening test
None of the above

In a patient with low back pain and stiffness for > 3 months that improves with exercise but not with rest, which of the following would confirm a
definite diagnosis of AS, according to the modified New York criteria for AS?
Both sacroiliac joints showing evidence of some sclerosis and minimal erosions, but joint space is not narrow

The right sacroiliac joint shows definite sclerosis on both sides of the joint, erosions, and widening of the interosseous space; the left
sacroiliac joint does not show clear abnormalities
The left sacroiliac joint shows complete joint obliteration without sclerosis; the right sacroiliac joint does not show clear abnormalities
Any of the above

Although there are well-established criteria for the radiographic evidence of sacroiliitis (New York criteria) (Table 4), it can be difficult to
distinguish between grades 1 and 2 sacroiliitis, which is currently the borderline between disease and no disease. Nonetheless, the presence
of grade 2 sacroiliitis bilaterally by radiography has remained one of the criteria for a couple of reasons: First, the imaging sensitivity would
have decreased significantly if only patients with grade 3 sacroiliitis had been included. Second, there was no better imaging technique
available for early diagnosis at the time when these criteria were developed. This issue was also investigated in a Dutch study, which reported
that the specificity and sensitivity of sacroiliitis on x-rays as read by trained radiologists or rheumatologists are only about 70% to 75% and
80% to 84%, respectively.[12] Of note, the presence of sacroiliitis alone does not necessarily represent definite AS, and requires the added
presence of 1 or more clinical feature(s) in order to make a definitive diagnosis.

Table 4. The New York Criteria for Grading Radiologic Evidence of Sacroiliitis[13]

Grade Label Description


0 Normal Clear joint margins, uniform joint width, and no juxta-articular sclerosis

1 Suspicious Suspicious but not definite abnormality

2 Minimal sacroiliitis Evidence of some sclerosis and minimal erosions, but no marked interosseous (joint space) narrowing
3 Moderate sacroiliitis Definite sclerosis on both sides of the joint, and erosions or widening of the joint space

4 Ankylosis Complete joint obliteration of the sacroiliac joints with or without residual sclerosis

A 26-year-old, African-American man presents with low back pain for 6 months that improves with exercise but not with rest. He reports morning
stiffness for 2 hours. On exam, lumbar spine mobility was normal in both the sagittal and frontal planes, and chest expansion was normal. An
anteroposterior pelvic x-ray did not show any evidence of sacroiliitis. Which of the following is the most appropriate next step?
Reassure the patient that this is a nonspecific musculoskeletal pain because spinal mobility and pelvis x-ray are normal, and recommend a
program of regular exercises
Order an HLA-B27 test

Order MRI of the sacroiliac joints and lumbar spine without gadolinium enhancement
Recommend annual anteroposterior pelvic radiography because radiographic evidence of sacroiliitis may sometimes take several years to
evolve
None of the above

During the early stages of AS, measures of spine mobility may be normal and radiographic evidence of sacroiliitis may be lacking. This
patient has a history of inflammatory back pain, and AS cannot be ruled out at this stage. Therefore, simply labeling this case as nonspecific
musculoskeletal pain would be inappropriate. Further testing should be sough to confirm or rule out the diagnosis. Repeating pelvis film
annually would result in unnecessary delay in the diagnosis and excessive gonadal radiation.

The prevalence of HLA-B27 and the strength of its association with AS markedly differ among various ethnic and racial groups worldwide. For
example, HLA-B27 is present in 3% of the African-American general population and only in approximately 50% of African-American patients
with
AS.[11,16] Thus, a negative test will not be clinically helpful in this patient, although a positive test would be very helpful.[11]

Therapeutic Options for AS

Which of the following nonbiologic treatments has been shown to be effective in treating axial manifestations of AS?
Celecoxib

Methotrexate
Sulfasalazine
Leflunomide
All of the above

Traditional disease-modifying antirheumatic drugs (DMARDs), such as sulfasalazine,[19] methotrexate,[20] and leflunomide,[21] have not been
demonstrated to be effective in the treatment of axial manifestations of AS.

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Which of the following biologic therapies have been shown in clinical trials to be effective in controlling symptoms of AS?
Adalimumab, infliximab, and rituximab

Adalimumab, etanercept, and infliximab


Abatacept, etanercept, and infliximab
Abatacept, adalimumab, and rituximab
Etanercept, infliximab, and rituximab

All 3 TNF-alpha inhibitors have been FDA-approved for treatment for the treatment of psoriasis; infliximab is approved for use in patients with
inflammatory bowel diseases (ulcerative colitis and Crohn's disease); and adalimumab is approved for Crohn's disease.

All 3 TNF-alpha inhibitors have been shown to have consistent efficacy in controlling the symptoms and signs of AS.[22-25] Infliximab is
administered by intravenous infusion at a dose of 5 mg/kg (as a loading dose at weeks 0, 2, and 6 and subsequently every 6-8 weeks) (Figure
1). Etanercept is administered subcutaneously at a dose of 50 mg once weekly (or 25 mg twice weekly) (Figure 2). Adalimumab is
administered subcutaneously at a dose of 40 mg every other week (Figure 3).

Figure 1. Proportion of patients who achieved 20% (ASAS20) (A) and 40% (ASAS40) (B) improvement responses during 24
weeks, according to the criteria of the ASsessment in Ankylosing Spondylitis (ASAS) International Working Group when treated
with infliximab vs those treated with placebo. *= P < .001.[22]

Figure 2. Achievement of the ASsessment in Ankylosing Spondylitis (ASAS)20 and ASAS40 responses in patients with
ankylosing spondylitis treated with etanercept (A) or placebo for the first 24 weeks and then switched to etanercept (B). After
192 weeks of etanercept exposure, the ASAS20 response was 81% and ASAS40 response was 69% in completer's analysis
(for all patients remaining in the trial at that time) (A).[23] Not shown are ASAS20 and ASAS40 responses when calculated for
the subjects who had at least 1 postdose assessment, using last observation carried forward for missing data imputation. These
responses were 67% for ASAS20 and 49% for ASAS40.

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Figure 3. Adalimumab vs placebo: percentage of patients who achieved ASAS20 response during 24 weeks, according to the
ASsessment in Ankylosing Spondylitis (ASAS) International Working Group criteria for improvement. *= P < .001.[25]

Abatacept and rituximab have been shown to be effective in management of rheumatoid arthritis but have not been shown to have efficacy in
treating AS.

The current ASsessment in Ankylosing Spondylitis (ASAS) guidelines for the use of anti-TNF therapy in patients with AS require the following
except:
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score ≥ 4 on a scale of 0-10
Lack of adequate response (or intolerability or contra-indication) to an NSAID given at maximum recommended or tolerated
anti-inflammatory dose during a 1-month period
Patients with symptomatic peripheral arthritis should have an insufficient response to at least 1 local corticosteroid injection if appropriate
Patients with persistent peripheral arthritis must have had a therapeutic trial of sulfasalazine

At least 50% improvement in BASDAI score (or absolute change of 2 on a scale of 0-10) in 6-12 weeks of anti-TNF therapy and "expert"
opinion

The first update of the international recommendations for use of anti-TNF agents in the treatment of AS was published in 2006.[26] The updated
recommendations include consensus statements to guide clinical practice, and provide a basis for developing national guidelines. The ASAS
guidelines for the use of anti-TNF therapy in patients with AS are detailed in Table 5.

Table 5. ASAS Guidelines for the Use of Anti-TNF Therapy in Patients With AS[26]

Diagnosis

Patients normally fulfilling modified New York criteria for definitive AS

Disease Activity

BASDAI score ≥ 4 (scale 0-10 cm) and

Physician global assessment by "expert" opinion (yes/no)

Previous Treatment

All patients should have had adequate therapeutic trials of at least 2 NSAIDs for at least 3 months at maximum recommended or
tolerated anti-inflammatory dose unless contraindicated or treatment was withdrawn because of intolerance, toxicity, or
contraindications.

Patients with pure axial manifestations do not have to take DMARDs before anti-TNF treatment can be started.

Patients with symptomatic peripheral arthritis should have an insufficient response to at least 1 local corticosteroid injection, if
appropriate.

Patients with persistent peripheral arthritis must have had a therapeutic trial of sulfasalazine.

Patients with symptomatic enthesitis must have failed appropriate local treatment.

Dosing

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Etanercept 50 mg subcutaneously once a week (or 25 mg twice a week)

Infliximab 5 mg/kg IV every 6-8 weeks

Adalimumab 40 mg subcutaneously every other week

Responder Criteria

50% improvement of BASDAI or absolute change of 2 on 0- to 10-cm scale and "expert" opinion

Time of Evaluation

Between 6 and 12 weeks

TB Precaution

Use country-specific guidelines

ASAS = ASsessment in Ankylosing Spondylitis; TNF = tumor necrosis factor; AS = ankylosing spondylitis; BASDAI = Bath
Ankylosing Spondylitis Disease Activity Index; NSAIDs = nonsteroidal anti-inflammatory drugs; DMARDs =
disease-modifying antirheumatic drugs; IV = intravenous; TB = tuberculosis

This activity is supported by an independent educational grant from Abbott.

References

[ CLOSE WINDOW ]

References

1. Elyan M, Khan MA. Diagnosing ankylosing spondylitis. J Rheumatol Suppl. 2006;78:12-23. Abstract
2. Haywood KL, Garratt AM, Jordan K, Dziedzic K, Dawes PT. Spinal mobility in ankylosing spondylitis: reliability, validity and
responsiveness. Rheumatology (Oxford). 2004;43:750-757. Abstract
3. Khan MA. Update on spondyloarthropathies. Ann Intern Med. 2002;136:896-907. Abstract
4. Lautermann D, Braun J. Ankylosing spondylitis -- cardiac manifestations. Clin Exp Rheumatol. 2002;20(suppl28):S11-S15.
5. Yagan R, Khan MA. Confusion of roentgenographic differential diagnosis between ankylosing hyperostosis (Forestier's disease) and
ankylosing spondylitis. Clin Rheumatol. 1983;2:285-292. Abstract
6. Hayem G, Bouchaud-Chabot A, Benali K, et al. SAPHO syndrome: a long-term follow-up study of 120 cases. Semin Arthritis Rheum.
1999;29:159-171. Abstract
7. Olivieri I, Gemignani G, Camerini E, et al. Differential diagnosis between osteitis condensans ilii and sacroiliitis. J Rheumatol.
1990;17:1504-1512. Erratum in: J Rheumatol. 1991;18:790.
8. Rudwaleit M, Listing J, Brandt J, Braun J, Sieper J. Prediction of a major clinical response (BASDAI 50) to tumour necrosis factor
alpha blockers in ankylosing spondylitis. Ann Rheum Dis. 2004;63:665-670. Abstract
9. van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the
New York criteria. Arthritis Rheum. 1984;27:361-368. Abstract
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Abstract

Authors and Disclosures


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activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as
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Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug
Administration, at first mention and where appropriate in the content.

Author

Muhammad A. Khan, MD, FRCP, MACP,

Professor of Medicine, Case Western Reserve University School of Medicine, MetroHealth


Medical Center, Cleveland, Ohio

Disclosure: Muhammad A. Khan, MD, FRCP, MACP, has disclosed that he has served as an
advisor or consultant to, and as a visiting speaker for, Abbott, Amgen/Wyeth, and
Centocor/Schering-Plough.

Mazen Elyan, MD

ssistant Professor, Division of Rheumatology, Case Western Reserve University at MetroHealth Campus, Cleveland,
Ohio; Attending Physician, Department of Medicine/Rheumatology, MetroHealth Medical Center, Cleveland, Ohio

Disclosure: Mazen Elyan, MD, has disclosed no relevant financial relationships.

Editor

Helen Fosam, PhD

Editorial Director, Medscape Rheumatology

Disclosure: Helen Fosam, PhD, has disclosed no relevant financial relationships.

Registration for CME credit, the post test and the evaluation must be completed online.
To access the activity Post Test and Evaluation link, please go to:
http://www.medscape.com/viewprogram/12637_index

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