QD96 - Dx & Rx Of Peripheral Spondyloarthr Save

Hi. This is QT clinic. I'm Jack Cush with RheumNow. QT clinic is brought to you by RheumNow and where you spend your time smartly when going to a virtual meeting like the ACR. Consider it.

This case is the diagnosis and treatment of peripheral spondyloarthritis. The patient is a 25 year old, African American female who is b twenty seven positive. She presented to me a few years ago with recurrent uveitis and hip pain. Turns out she would have intermittent nesenovitis and effusions that would need to be drained, occasionally injected. She was on nonsteroidals.

She's been through the ringer, meaning she's had recurrent uveitis. She's without damage, thankfully. She's had, recurrent knee effusions and oligoarthritis. She's had severe progressive hip disease and damage requiring a total hip replacement. All the while, a few years of this while taking etanercept and then adalimumab and then cerdulizumab and then IV golimab.

And, you know, they kinda worked. They might have been better at controlling her uveitis than her arthritis, but, boy, it never really worked. So what happened next? We put her on an IL-seventeen inhibitor. We put her on secukinumab thinking this will work.

This will be great. Wrong. Four months of that was horrendous, like, really, a few of the TNF inhibitors she took. I mean, it's really unusual why she doesn't seem to respond to anything. And then we put her on afliximab, and now she's had a miraculous response.

I mean, five milligrams per kilogram has been just fabulous. So where are the pitfalls here? Number one, the diagnosis. Peripheral spondyloarthritis means no axial disease. Her diagnosis is established by her uveitis.

She had some early inflammatory like back pain, but I wasn't convinced. Her X rays of her SI joint multiple times have been negative. She's had hip damage and hip replacements. She's had Achilles tendonitis, and she's had an oligosynovitis in the knees. So she meets the ASAS classification criteria.

Look. This is what they show. You can see on the right, if you have peripheral arthritis, you can have enthesitis and have the diagnosis, or you can have arthritis, enthesitis, and inflammatory low back pain. Again, she's been cinched by having her recurrent uveitis and her peripheral inflammatory disease. She happens to be b twenty seven negative, yet she responds very well to drugs that would work just as well in B27 positive individuals.

So the diagnosis needs to be established and a little more difficult in people who have peripheral disease. The next is going to be treatment, and she's been difficult. Nosteroidals, no effect. Steroids, intra articulately, some effect, but really oral, no effect at all. And then she's been through the ringer.

Three and a half, four years, four biologics, TNF inhibitors, no effect. Another less than half year with an IL seventeen inhibitor, really no effect there. And it wasn't till she got afliximab. So the point is maybe sometimes you do have to go through five TNF inhibitors. My goodness, that's so far against what I have said in the past.

But, you know, live and learn. Trial and error is sometimes the best way to learn. I'm glad she's doing very well on this, but you have to be persistent. The question is, what would happen if she didn't respond to the, moderate to high dose of infliximab? She's on five milligrams per kilogram.

Well, number one, IL twenty three inhibitors don't seem to have much effects in axial disease. Note not sure what they would do with peripheral spondylarthropathy. Not been tested. Next, your option could be another IL seventeen inhibitor like aixekizumab or any of the others coming up in the future. Would she do well with an IL twelve twenty three inhibitor like, ustekinumab?

I probably would not try her on aprimilast because I'm not sure it really would work in something like this. But those are the remaining options when really frustrated, and, thankfully, I'm not really frustrated on this case. That's it for this episode of QD Clinic. Tune in for more.