THE OFFICIAL NEWS SOURCE OF ACR CONVERGENCE 2022 • NOVEMBER 10-14



Learn how to answer SpA patients’ tough questions

Patients have questions — serious, often difficult, questions — about ankylosing spondylitis and other forms of spondyloarthritis (SpA). A state-of-the-art lecture will answer many of those questions on Monday afternoon.

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Robert Inman, MD

Robert Inman, MD, Professor of Medicine and Immunology at University Health Network and University of Toronto, will offer the latest data and current thinking in response to common patient questions during Current State of the Art in Spondyloarthritides (SpA): Tough Questions Your SpA Patients Might Ask You. Unlike most clinical sessions that address issues that are important to rheumatologists, this lecture addresses issues that are important to patients.

“The ACR is all about enhancing quality of life and functioning for our patients,” Dr. Inman said. “Structuring this session around the questions that patients ask us rather than the questions physicians ask each other is keeping patient well-being at the center of the discussion.”

One of the most common questions involves the relationship, if any, between spondyloarthritis and diet. There are multiple opinions but few data and even less consensus.

“This is a very common question for which we have no good answer,” Dr. Inman said. “It raises the question as to whether there is subclinical bowel inflammation. There is some evidence that more than half of patients with ankylosing spondylitis have some clinical bowel inflammation. Ten percent have overt Crohn’s disease or ulcerative colitis. There is some indication that asymptomatic inflammatory bowel disease is more common than we recognize in spondyloarthritis, but even in the IBD literature there is no consensus on diet.”

Patients often try multiple diets to manage their symptoms, including gluten-free, lactose-free, low carbohydrate, high carbohydrate, and more. Many patients report positive results, but clinicians have little more than anecdotes when it comes to answering questions.

But recent data provide good news when it comes to answering common questions about nonsteroidal anti-inflammatory agents (NSAIDs). Patients typically ask if their disease can be managed using NSAIDs alone, Dr. Inman said, a common question for patients who are taking only NSAIDs.

The usual follow up is a series of questions about biologics. One common question is why to start an anti-TNF agent, he said, although patients often start by asking the best time to start biologic therapy. The discussion often segues into vaccinations, including questions about which vaccinations are useful, which vaccinations should be avoided, and the general impact of biologics on vaccination schedules.

Comorbidities are another common area of concern. Patients have likely read about the potential risks of infection or cancer associated with biologic therapy or cardiovascular risks with certain NSAIDs, but they may not have read the most recent findings or may not read too much into a particular study that does not match their particular disease or treatment regimen.

“We have data on things like the risks of nonsteroidals on cardiovascular disease and the risks of a biologic on cancer or opportunistic infection,” he said. “We have some very good data on some of these common questions.”

One of the most often-ignored areas is emotional impact of the spondyloarthritis. Patients may ask about mood swings but seldom ask about underlying emotional issues.

“These are primarily young people, so depression and anxiety around their disease is an important part of the discussion,” Dr. Inman said. “It has to do with how effectively we deliver meaningful prognostic information. These are typically young people in the midst of their social and career years. It’s a big issue to think that you’ve got a chronic illness, especially when we’re superimposing the issue of a biologic. We’re proposing to people in their 20s or 30s that they have to get regular injections indefinitely to control their disease. Conceptually, it is straightforward, but there is a significant emotional dimension to this disease that needs to be discussed.

“From women with AS there are commonly questions about the impact of pregnancy on the course of AS, and the management of their AS during the course of the pregnancy,” he said. “A related concern is the likelihood that their kids will also be affected by AS. These questions, if left unanswered, can also be a source of anxiety for the patients.”