An interview with Steve Lee, DO, FACR, rheumatologist and member of SAA’s Medical and Scientific Advisory Board.
We’re continuing our exploration of the possible impacts of long-standing spondyloarthritis (SpA) that we began with Dr. Muhammad Asim Khan in our Summer 2021 issue of Spondylitis Plus. Many thanks to Dr. Steve Lee for contributing his expertise to this important topic.
Spondylitis Plus: Can we discuss the risks of osteoporosis and fractures in long standing SpA? Who is at heightened risk? Why? And what screenings and preventative measures are recommended?
Dr. Steve Lee: Several factors can predispose one to osteoporosis and complications of fractures. First, many patients limit their physical activity due to pain and mobility challenges. Certainly exercise, and in particular moderate weight bearing activity, helps keep our bones strong and muscles firm to support posture and function. Those who aren’t incorporating activity into their routines are missing out on this protective measure. Next, SpA patients typically form extra bone in the spine, pelvis and other sites, and chronic inflammation can lead to abnormal architecture and osteoporosis. Finally, when one needs intubation for surgery or severe illness, a neck that has limited flexibility can suffer the rare surgical complication of neck fracture.
Those with low vitamin D, smokers, and those with poor nutrition including inadequate calcium are at greater risk for osteoporosis. Women generally have greater risk as well. Screening for women generally starts at age 65, or earlier if risk factors like SpA, family history, smoking, or others are present. Men generally start later but guidelines are variable. All of us lose some bone gradually as we age. Most SpA patients are not on chronic steroids, but this can also be a risk.
Spondylitis Plus: What are the long-term risks and implications of recurring iritis/uveitis? What is recommended for a patient experiencing regular bouts of iritis?
Dr. Steve Lee: Recurring inflammation in the eyes can ultimately lead to impaired vision and vision loss. Topical steroids can increase the risk for infection and can accelerate cataracts, which also impair vision. Ongoing monitoring by your team of ophthalmology and rheumatology specialists can help calm the inflammation. In particular, the TNF inhibitors, aside from etanercept [Enbrel], seem to be quite effective in the treatment and prevention of iritis/uveitis.
Spondylitis Plus: How common is spinal stenosis in long standing spondyloarthritis? And does SpA cause, or at least contribute to it? If so, how?
Dr. Steve Lee: Spinal stenosis is the result of degeneration and extra bone growth in the spine that can lead to narrowing of the spinal column. This can cause chronic low back pain that can radiate and tends to improve when one leans forward. Though the symptoms of spinal stenosis are different from those of SpA and bone growth in SpA tends to be marginal (less bulky than in spinal stenosis, and with less encroachment into the spinal canal itself), spinal stenosis can accelerate with spondyloarthritis, especially as we age.
Spondylitis Plus: What are some indicators that a consideration of surgery is warranted? (Kyphosis, hip surgery, joint replacement, etc.)
Dr. Steve Lee: Thankfully, fewer SpA patients are requiring posture correcting surgery of the spine and hips, largely due to the potent and effective medications that have been developed over the past 23 years. But if enough damage occurs over time to limit function or range of motion in the neck or hips in particular, surgery – though complex – can be helpful. Hip replacement is sometimes used if cartilage is lost, and various spinal column straightening procedures may be performed, but require a highly skilled and experienced surgeon.
Spondylitis Plus: Are those with SpA more likely to need joint replacement (such as the hip or knee) than the general population? If so, do we know why? What mechanisms in SpA may be contributing factors?
Dr. Steve Lee: The chronic inflammation that occurs in SpA can accelerate cartilage loss, in particular in the hips and axial skeleton (spine and pelvis). Some with peripheral SpA may require knee replacement as well. Most biologics need to be held for some time prior to planned surgeries. Complications like infections, abnormal bone growth (heterotopic ossification) and challenging rehabilitation can complicate surgical procedures.
Spondylitis Plus: Pain, fatigue, and brain fog. There aren’t great answers for these. What do you tell patients who are suffering from uncontrolled pain, fatigue, and brain fog?
Dr. Steve Lee: Though no one treatment works for all patients, there are numerous options for even stubborn SpA inflammation. Many with chronic inflammation report significant fatigue and even cognitive symptoms like brain fog. The prevention and control of inflammation and patterns of pain that can become chronic are key to managing these symptoms. A multi-disciplinary approach led by teams of physicians may be needed. Rheumatologists, physiatrists, orthopedic and spine surgeons, and mental health clinicians can all help us in our daily function. Pain specialists can incorporate options like acupuncture, botanicals, mindfulness, and analgesic strategies to help patients cope. Certainly, optimizing restful sleep and healthy nutrition may also be helpful.
Spondylitis Plus: Patients have heard that aneurysms may be brought on as part of the comorbidities of spondyloarthritis. Can you speak to this concern?
Dr. Steve Lee: Thankfully, aneurysms are rare and not likely directly related to SpA, but cardiac complications like a dilated aorta have been documented. Most physicians will periodically listen to your heart and abdominal aorta, and check for symptoms of heart problems.
Spondylitis Plus: What should those living with long-term SpA know that may be comforting? How do you reassure patients?
Dr. Steve Lee: There have been many exciting advances in the past couple of decades in SpA research! There has been a major push for earlier diagnosis, looking at genes that make a person more susceptible to SpA, and continuing to explore gender differences. Researchers are also studying mechanisms of disease pathogenesis [development], in particular the microbiome. From this knowledge, new areas of targeted therapies that block inflammation-causing parts of our immune system are being developed and can now be used in clinics to get symptoms under excellent control in many instances. Medications are becoming more accessible as well, as competition increases in the areas of biosimilars and upcoming oral formulations of anti-inflammatory medications. So there is reason to believe our understanding and treatment of SpA will continue to advance significantly into the future!
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