1. Axial Spondyloarthritis
Epidemiology in South East Asia
and Patient Journey
James Cheng-Chung WEI, MD, PhD
Chief, Division of Allergy, Immunology and Rheumatology
Director, Chinese Medicine Clinical Trial Center
Associate Professor, Chung Shan Medical University

2. Outline

Concept of SpA
• and non-radiographic axial spondyloarthritis
(nr-axSpA)
Epidemiology of SpA in South East Asia
 Patient journey
 Take home message


3. Spectrum of Spondyloarthritis.
(seronenative spondyloarthropathies)
AS, ankylosing spondylitis; PsA, psoriatic arthritis; ReA, reactive arthritis; IBD,
inflammatory bowel diseases-associated arthritis; USpA, undifferentiated spondyloarthritis.
JC Wei. Chronic Inflammation: Causes, Treatment Options and Role in Disease. Nova
Science Publishers, Inc. 2013

4. MNY, 1984
ASAS, 2009
ASAS, 2011

5. Non-radiographic axial spondyloarthritis
(nr-axSpA)
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Fit axial SpA (ASAS classification criteria for
axSpA, Rudwaleit et al 2009)), but not
radiographic criteria of AS (Modified New York
criteria, Calin et al 1984).
Usually early or mild or atypical cases
Some of them might develop AS and have
similar health burden.
New disease entity
• Adalimumab in nx-axSpA: approved by EMEA, but not FDA
• Certolizumab Pegol in axSpA approved by EMEA & FDA

6. Outline

Concept of SpA
• and non-radiographic axial spondyloarthritis
(nr-axSpA)
Epidemiology of SpA in South East Asia
 Patient journey
 Take home message


9. Epidemiological survey in China
N=10 921 , aged >16 years; of these,
 7.21% had LBP
 0.78% axial SpA(12% in subjects with LBP)
 0.25% ankylosing spondylitis (AS)
 0.50% undifferentiated axial SpA (USpA)
 0.02% psoriatic arthritis (PsA)

Of the axial SpA patients, 82.67% were HLA-B27
positive, clearly a greater percentage than those
(11.65%) in other LBP groups.
Liao, Gu. Scand J Rheumatol. 2009 Nov-Dec;38(6):455-9.

10. AS in Taiwan
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Population: 23 million
5% were HLA-B27 positive
92% HLA-B27 positive
AS prevalence: 0.2-0.4 %
Sex ratio (M:F) was 2.8 : 1
Delay diagnosis 5.9 years
42.6％ have family history of
SpA
JC Wei, PhD thesis, 2007, Clinical Rheumatology (2007) 26:1685–1691

11. Extra-articular manifestations of
AS in Taiwan, n=805
Variables
Patient (%)
History of uveitis, no. (%)
History of psoriasis, no. (%)
History of hematuria no. (%)
History of oral ulcer, no. (%)
Onset symptom, no. (peripheral
arthritis / IBD / uveitis) (%)
24.1
13.9
6.8
11.6
21.5/2.9/2.5
JC Wei. Clinical Rheumatology (2007) 26:1685–1691

12. Outline

Concept of SpA
• and non-radiographic axial spondyloarthritis
(nr-axSpA)
Epidemiology of SpA in South East Asia
 Patient journey
 Take home message


15. Progression of Non-radiographic Axial SpA to AS:
Data from GESPIC*
Non-radiographic axial SpA
Ankylosing spondylitis
12%
in 2 years
Main predictor:
elevated CRP**
no definite radiographic sacroiliitis (grade 0 at the right side,
grade 1 – possible subchondral sclerosis – at the left side)
definite radiographic sacroiliitis (grade 2 bilaterally) fulfilling
the radiographic criterion of the modified New York criteria
*GESPIC = GErman Spondyloarthritis Inception Cohort
**Odds ratio for progression in patients with elevated serum C-reactive protein level (>6 mg/l) was:
4.11 (95% CI 1.13-14.95).
Poddubnyy D et al. Ann Rheum Dis 2011;70:1369-74

17. How to identify SpA pts?
LBP
Low back pain
IBP Dx by general physicians
IBP
Referral
Inflammatory back pain
SpA Dx by rheumatologists
SpA
Spondyloarthritis

21. Unmet Needs of SpA in Asia
Unmet needs
Actions to do
1. Educate GP and rheumatologist
about new concepts of SpA
2. When to see a rheumatologist,
ie. Refer strategy for GP and Pt
3. When and how to test X-ray,
HLA-B27, MRI
Inadequate treatment 1. Educate Pt and GP
2. Accessibility and cost of TNFi
3. Safety, esp TB and HepB
Delayed diagnosis

22. Take Home Message
1.
2.
3.
4.
5.
6.
SpA affect 1% of population with variable features.
SpA cause severe health burden due to delay
diagnosis and inadequate treatment in Asia.
Need practical referral strategy to identify patients.
ASAS criteria for IBP and axSpA is useful for clinical
studies and daily practice
Diagnose nr-axSpA by HLA-B27 and/or MRI.
Accessibility of TNFi and safety, esp TB and HepB
are major concerns in SEA.