Chapter 29: Disorders of the Skin, Breast, and Musculoskeletal System

ANKYLOSING SPONDYLITIS AND SPONDYLOARTHRITIS

Population

• –Adults with ankylosing spondylitis (AS) or nonradiographic spondyloarthritis.

Recommendations

ACR/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015

• –Recommendations for treatment of ankylosing spondylitis

  • Scheduled NSAIDs.

  • Tumor necrosis factor inhibitor (TNFi) therapy.

  • Recommends addition of slow-acting anti-rheumatic drugs when TNFi medications contraindicated.

  • Local parenteral corticosteroids for active sacroiliitis, active enthesitis, or peripheral arthritis for symptoms refractory to NSAIDs.

  • Avoid systemic corticosteroid use.

  • Refer to an ophthalmologist for concomitant iritis.

  • Recommend TNFi monoclonal antibody therapy for AS with inflammatory bowel disease.

  • Physical therapy program.

  • Screen for fall risk, osteoporosis.

• –Recommendations for treatment of nonradiographic axial spondyloarthritis

  • NSAIDs.

  • Tumor Necrosis Factor inhibitor (TNFi) therapy.

Source

• –Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol. 2016;68(2):282-298.

ATOPIC DERMATITIS (AD)

Population

• –Adults and children.

Recommendations

AAD 2014

• –Generous application of skin moisturizers after bathing.

• –Recommend limited use of hypoallergenic nonsoap cleansers.

• –Consider wet-wrap therapy with topical corticosteroids for moderate-to-severe AD during flares.

• –Twice-daily topical corticosteroids are the first-line therapy for AD.

• –Topical calcineurin inhibitors (tacrolimus or pimecrolimus) can be used for maintenance AD therapy.

• –Recommend against topical antihistamine therapy for AD.

• –Phototherapy is second-line treatment for refractory cases.

• –Consider systemic immunomodulating agents for severe cases that are refractory to topical agents and phototherapy.

Sources

• –http://www.guideline.gov/content.aspx?id=48409

• –http://www.guideline.gov/content.aspx?id=48410

Comment

1. Systemic immunomodulating agents that have been studied in AD are azathioprine, cyclosporine, or methotrexate.

BACK PAIN, LOW

Population

• –Adults.

Recommendations

ACP 2017

• –Consider nonpharmacologic treatments for acute or subacute low-back pain including superficial heat, massage, acupuncture, or spinal manipulation.

• –If pharmacologic treatments needed, start with NSAIDs or skeletal muscle relaxants.

• –For chronic low back pain, start a trial of nonpharmacologic treatments including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, biofeedback, cognitive behavioral therapy, or spinal manipulation.

• –For persistent chronic low-back pain, pharmacologic therapy with NSAIDs as first-line therapy and tramadol or duloxetine as second-line therapy.

• –Use opiates for chronic low-back pain only if patients have failed all other therapies and only if the potential benefits outweigh the risks of dependency, addiction, overdose, and misuse.

Sources

• –http://guidelines.gov/summaries/summary/50781/noninvasive-treatments-for-acute-subacute-and-chronic-low-back-pain-a-clinical-practice-guideline-from-the-american-college-of-physicians?q=back+pain

• –Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern ...