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Q1: Presentation and diagnosis (2 min)
- Define ankylosing spondylitis. A chronic, progressive, inflammatory disease of the axial skeleton and entheses — the prototype of the seronegative spondyloarthropathies; strongly HLA-B27 associated.
- What is inflammatory back pain? The Calin/ASAS criteria: onset under 45 years, more than 3 months, insidious, morning stiffness, improves with exercise (not rest), alternating buttock pain, second-half-of-night waking.
- Name the diagnostic criteria. Modified New York (1984) — radiographic sacroiliitis (bilateral grade 2 or unilateral grade 3) plus one clinical criterion; ASAS 2009 — captures the wider axial SpA spectrum including non-radiographic disease (imaging arm: sacroiliitis on imaging plus one SpA feature; clinical arm: HLA-B27 plus two SpA features).
- What is the earliest imaging finding? Bone-marrow oedema of the SI joint on MRI STIR/T2 fat-saturated sequences; precedes plain X-ray change by years.
Q2: Management (3 min)
- What is the treat-to-target goal? Clinical remission or low disease activity — ASDAS under 1.3 (or BASDAI under 4 with normal CRP).
- First-line therapy? Continuous full-dose NSAID (naproxen 500 mg BD or indometacin 25 to 50 mg TDS) plus daily physiotherapy; continuous NSAID may slow radiographic progression.
- When do you use a biologic? Persistent high disease activity (ASDAS 2.1 or more, or BASDAI over 4 on two occasions) despite NSAIDs — TNFi first (adalimumab 40 mg SC q2w, etanercept 50 mg SC weekly, infliximab 5 mg/kg IV q6 to 8w, golimumab 50 mg SC monthly, certolizumab 400 mg SC q4w) or IL-17i (secukinumab 150 mg SC monthly).
- Pre-biologic screen? TB (IGRA and CXR), HBV, HCV, HIV; treat latent TB (isoniazid 300 mg for 6 to 9 months) before starting.
- Role of csDMARDs? Sulfasalazine and methotrexate are NOT effective for axial disease — only for peripheral arthritis.
- Why avoid systemic steroids? Ineffective for axial AS; use local glucocorticoid injections for focal disease.
- Which biologic is preferred if recurrent uveitis or IBD? A TNF-inhibitor monoclonal (adalimumab, infliximab, golimumab, certolizumab) — avoid etanercept and avoid IL-17i in IBD.
Q3: Complications and emergencies (2 min)
- The five emergencies: acute anterior uveitis (topical steroid plus cycloplegic, urgent ophthalmology); spinal fracture after minor trauma in a fused spine (immobilise, whole-spine CT/MRI); cauda equina syndrome (urgent MRI, neurosurgery); aortic regurgitation/AV block (cardiology); latent TB before biologic.
- Systemic complications: aortic regurgitation and aortitis, AV block, apical lung fibrosis (can cavitate and mimic TB), secondary (AA) amyloidosis, IgA nephropathy, atlantoaxial subluxation.
- Ocular emergency: acute anterior uveitis is unilateral, painful and red; untreated attacks cause synechiae, glaucoma and cataract.
Q4: Prognosis and special populations (2 min)
- Prognosis is variable. Predictors of severe progression: male sex, young onset, family history, HLA-B27, elevated CRP, smoking, baseline structural damage, hip arthritis (strongest predictor of poor functional outcome).
- Pregnancy: NSAIDs safe in first and second trimester, avoid after 28 to 30 weeks; certolizumab preferred (no placental transfer); methotrexate contraindicated; sulfasalazine safe with folic acid (causes reversible male infertility — counsel men).
- Elderly: lower NSAID threshold; prefer COX-2 selective or IL-17i; assess fracture and cardiovascular risk.
- nr-axSpA: 10 to 30 percent progress to radiographic AS over 10 years; treatment identical to AS.
- Mortality is modestly increased — driven by cardiovascular disease, spinal fracture and amyloidosis; aggressive CV risk-factor modification is part of routine care.