Hvad omfatter denne NBV



Aksial spondylartritNational behandlingsvejledning (NBV): Aksial spondylartritis herunder ankyloserende spondylitisUdarbejdet for Dansk Reumatologisk Selskab af:Anne Gitte Loft1 (formand), Annette Schlemmer2 (tovholder). Oliver Hendricks3, Hans Christian Horn4, Susanne Juhl Pedersen5, Randi Pelck6, Inge Juul S?rensen7. For Dansk Radiologisk Selskab:Anne Grethe Jurik8?1: Led- og Bindev?vssygdomme, Aarhus Universitetshospital2: Regionshospitalet Randers3: Dansk Gigthospital4: Reumatologisk Afdeling C, Odense Universitetshospital5: Afdeling for Rygkirurgi, led- og bindev?vssygdomme, Rigshospitalet6: Reumatologisk Afdeling, Sj?llands Universitetshospital K?ge7: Afdeling for Rygkirurgi, led- og bindev?vssygdomme, Rigshospitalet 8: R?ntgen og Skanning, Aarhus UniversitetshospitalGodkendt den XX.XX.XXXX. Revideres om 4 ?r (dvs. n?ste gang 2025)?Ansvarlig for den l?bende revidering af dokument er Anne Gitte Loft (formand) i samarbejde med Annette Schlemmer (tovholder)Indhold TOC \o "1-3" \h \z \u 1Hvad omfatter denne NBV PAGEREF _Toc58475041 \h 42Definition PAGEREF _Toc58475042 \h 42.1Kort beskrivelse og inddeling if?lge diagnosekoder (ICD10) PAGEREF _Toc58475043 \h 42.2Forekomst PAGEREF _Toc58475044 \h 52.3?tiologi og patogenese PAGEREF _Toc58475045 \h 53Diagnose og klinisk pr?sentation PAGEREF _Toc58475046 \h 53.1Klassifikationskriterier PAGEREF _Toc58475047 \h 63.2Symptomer PAGEREF _Toc58475048 \h 93.2.1Inflammatoriske rygsmerter PAGEREF _Toc58475049 \h 93.2.2Ekstra-aksiale symptomer PAGEREF _Toc58475050 \h 93.3Kliniske fund PAGEREF _Toc58475051 \h 93.3.1Aksiale fund PAGEREF _Toc58475052 \h 93.3.2Ekstra-aksiale fund PAGEREF _Toc58475053 \h 104Differentialdiagnoser og mulige sameksisterende tilstande PAGEREF _Toc58475054 \h 105Diagnostiske overvejelser og konklusion PAGEREF _Toc58475055 \h 116Henvisning og visitation PAGEREF _Toc58475056 \h 117Billeddiagnostik PAGEREF _Toc58475057 \h 127.1Flowdiagram for udredning PAGEREF _Toc58475058 \h 127.2Definitioner p? sakroiliitis ved axSpA/AS p? MR-skanning og RTG PAGEREF _Toc58475059 \h 137.3Beskrivelse af billeddiagnostiske unders?gelser PAGEREF _Toc58475060 \h 147.3.1MR-skanning PAGEREF _Toc58475061 \h 147.3.2R?ntgenunders?gelser PAGEREF _Toc58475062 \h 147.4Knogleskintigrafi PAGEREF _Toc58475063 \h 147.5Ved frakturmistanke PAGEREF _Toc58475064 \h 158Opf?lgning og monitorering PAGEREF _Toc58475065 \h 158.1Klinisk opf?lgning PAGEREF _Toc58475066 \h 158.2MR af SI-led og columna totalis mhp. opf?lgning PAGEREF _Toc58475067 \h 159Behandling PAGEREF _Toc58475068 \h 159.1Information til patienten og p?r?rende PAGEREF _Toc58475069 \h 169.2Tr?ningsterapi PAGEREF _Toc58475070 \h 169.2.1Vederlagsfri fysioterapi PAGEREF _Toc58475071 \h 169.3NSAID PAGEREF _Toc58475072 \h 179.4DMARD PAGEREF _Toc58475073 \h 179.5Glukokortikoid PAGEREF _Toc58475074 \h 179.6Biologiske l?gemidler (bDMARD) PAGEREF _Toc58475075 \h 189.6.1Indikation for behandling med bDMARD PAGEREF _Toc58475076 \h 189.6.2Pr?diktorer for effekt af behandling med TNFα-h?mmer PAGEREF _Toc58475077 \h 189.6.3Valg af bDMARD PAGEREF _Toc58475078 \h 189.7Vurdering af behandlingsrespons PAGEREF _Toc58475079 \h 199.8Behandlingsskift PAGEREF _Toc58475080 \h 199.9Dosisreduktion og/eller seponering ved remission PAGEREF _Toc58475081 \h 199.10Hyppige problemstillinger under behandling PAGEREF _Toc58475082 \h 199.11Kirurgi PAGEREF _Toc58475083 \h 2010DANBIO registrering PAGEREF _Toc58475084 \h 2011Komplikationer PAGEREF _Toc58475085 \h 2111.1Osteoporose PAGEREF _Toc58475086 \h 2111.2Columnafraktur PAGEREF _Toc58475087 \h 2111.3Kardiovaskul?r sygdom PAGEREF _Toc58475088 \h 2211.4Nyresygdom PAGEREF _Toc58475089 \h 2211.5Lungesygdom PAGEREF _Toc58475090 \h 2212Uddelegering af arbejdsopgaver til andre faggrupper PAGEREF _Toc58475091 \h 2213Patientens perspektiv PAGEREF _Toc58475092 \h 2214Aspekter vedr?rende MR-skanning PAGEREF _Toc58475093 \h 2314.1Tekniske krav til MR-skanning PAGEREF _Toc58475094 \h 2314.2Aktuel forskningsbaseret viden vedr. MR-fund ved axSpA/AS og relevante differentialdiagnoser. PAGEREF _Toc58475095 \h 2315Forkortelser PAGEREF _Toc58475096 \h 25Referencer PAGEREF _Toc58475097 \h 27Hvad omfatter denne NBVBehandlingsvejledning for non-radiografisk inflammatorisk aksial spondylartritis (axSpA) og ankyloserende spondylitis (AS) hos voksne. DefinitionKort beskrivelse og inddeling if?lge diagnosekoder (ICD10)AxSpA og AS omfatter en gruppe kroniske, inflammatoriske sygdomme, med smerter overvejende i glutealregionen og/eller ryggen af mere end 3 m?neders varighed, som opfylder de modificerede New York (NY) kriterier for AS ADDIN EN.CITE <EndNote><Cite><Author>van der Linden</Author><Year>1984</Year><RecNum>3547</RecNum><DisplayText>[1]</DisplayText><record><rec-number>3547</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184662">3547</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van der Linden, S.</author><author>Valkenburg, H. A.</author><author>Cats, A.</author></authors></contributors><titles><title>Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria</title><secondary-title>Arthritis and Rheumatism</secondary-title></titles><periodical><full-title>Arthritis and Rheumatism</full-title><abbr-1>Arthritis Rheum.</abbr-1><abbr-2>Arthritis Rheum</abbr-2><abbr-3>Arthritis &amp; Rheumatism</abbr-3></periodical><pages>361-368</pages><volume>27</volume><number>4</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Back Pain</keyword><keyword>HLA Antigens/genetics</keyword><keyword>Humans</keyword><keyword>New York</keyword><keyword>Rome</keyword><keyword>Spondylitis, Ankylosing/diagnosis/immunology/physiopathology</keyword></keywords><dates><year>1984</year></dates><pub-location>UNITED STATES</pub-location><isbn>0004-3591; 0004-3591</isbn><urls><related-urls><url>;[1] og/eller ASAS kriterierne for axSpAPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SdWR3YWxlaXQ8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFy

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ADDIN EN.CITE.DATA [2], j?vnf?r skemaerne nedenfor.AxSpA omfatter som begreb patienter, der opfylder ASAS kriterierne for axSpA uanset, om de opfylder eller ikke opfylder de modificerede NY kriterier. I denne NBV anvendes axSpA udelukkende om patienter, som ikke opfylder de modificerede NY kriterier for AS (dvs. non-radiografisk axSpA).AS, dvs. radiografisk axSpA, er defineret ved p?visning af forandringer ved konventionel r?ntgenunders?gelse j?vnf?r de radiologiske kriterier samt opfyldelse af den kliniske del af de modificerede NY kriterier for AS. Nedenst?ende diagnoser er implementeret i den landsd?kkende kliniske kvalitetsdatabase for reumatologi DANBIO.Det bem?rkes, at bidiagnoser er vigtige at tilf?je og justere l?bende, b?de i journal og i DANBIO, af hensyn til behandlingen samt den administrative opf?lgning af denne.Tabel 1: Diagnoser omfattet af NBV og ICD10 koder (International Classification of Diseases 10th Revision)Diagnoser omfattet af NBVICD-10 koderKommentarASDM45.9Opfylder de modificerede NY kriterierAS ved reaktiv artritisDM45.9 + DM02.9AS med psoriasisDM45.9 + DM07.2AS med Crohns sygdomDM45.9 + DM07.4AS med colitis ulcerosaDM45.9 + DM07.5AS med anterior uveitDM45.9 + DH20.0AxSpA uden specifikationDM46.9Opfylder ASAS, men ikke de modificerede NY kriterier. I Danmark anvendes alene den billeddiagnostiske arm i ASAS klassifikations kriteriet for axSpA (se tabel nedenfor). AxSpA ved reaktiv artritisDM46.8 + DM02.9AxSpA med psoriasisDM46.8 + DM07.2AxSpA med Crohns sygdomDM46.8 + DM07.4AxSpA med colitis ulcerosaDM46.8 + DM07.5AxSpa med anterior uveitisDM46.8 + DH20.0Diagnoser ikke omfattet af NBVJuvenil ASDM08.1Perifer psoriatisk artritisDM07.3AEntesopati i rygs?jlenDM46.0Sakroiliitis ikke klassificeret andetstedsDM46.1MR og/eller RTG p?vist sakroiliitis-lignende forandringer hos pt. uden symptomerICD-10 kode for perifer spondylartrit findes ikke. Pragmatisk anbefales det, at kodningen her er: DM 13.8, anden specificeret artrit.ForekomstHyppigheden af AS sk?nnes til ca. 0,5 %. Hyppigheden af axSpA sk?nnes til ca. 1,5 %.Kun 1-5?% af HLA-B27 (human leukocyt antigen subtype B) positive individer udvikler AS.F?rstegradssl?gtninge til patienter med AS har en 5-16?% risiko for at udvikle sygdommen.Klinisk findes inflammatorisk tarmsygdom (IBD) hos 5-10?% af patienter med AS og yderligere 70?% har subklinisk tarm inflammation.Psoriasis forekommer mindst 3 gange s? hyppigt hos AS patienter som i den generelle befolkning.?tiologi og patogenese ?tiologien til axSpA og AS er ukendt, men er formentlig betinget af et komplekst samspil mellem genetisk disposition og milj?m?ssige faktorerPEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGVyIExpbmRlbjwvQXV0aG9yPjxZZWFyPjE5ODQ8

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ADDIN EN.CITE.DATA [1-5]AxSpA og AS er associeret med mikroskopisk p?vist inflammation i tarmens slimhinde og tarmens bakterier menes at spille en rolle.Mindst 40 gener er associeret med AS omfattende s?vel HLA som ikke-HLA gener. Flere af disse gener er ogs? associeret med IBD, psoriasis og uveitis. Der er p?vist en association til interleukin-23 systemet, pr?sentation af peptider i HLA-systemet, differentiering og aktivering af innate og adaptive immunceller. Patogenesen ved axSpA og AS adskiller sig fra patogenesen ved reumatoid artrit, idet inflammationen er lokaliseret ved enteser og ikke i synovialis. Ved enteser forst?s omr?der, hvor annulus fibrosus, ligamenter, sener og ledkapsler f?ster sig til knoglen. Inflammationen medf?rer, at der udvikles knogledestruktion og dermed erosion, som i forbindelse med reaktive processer f?rer til knoglenydannelse, der som syndesmofytter eller paravertebral knoglenydannelse kan vokse hen over intervertebralrum og resultere i ankylotiske columnaforandringer (bamboo spine) eller hen over en ledspalter resulterende i ledankylose, f.eks. i SI-led. Diagnose og klinisk pr?sentation Der er ingen diagnosekriterier for axSpA, men alene klassifikationskriterierPEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGVyIExpbmRlbjwvQXV0aG9yPjxZZWFyPjE5ODQ8

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ADDIN EN.CITE.DATA [1, 2], som kan benyttes til at sandsynligg?re diagnosen, n?r de benyttes af specialister p? omr?det. AxSpA er en klinisk diagnose, hvor MR indg?r som et centralt element i den diagnostiske vurdering, men MR-p?vist knoglemarv?dem i SI-led er ikke i sig selv diagnostisk for axSpA. MR-fundene skal vurderes i sammenh?ng med patientens smerteanamnese, kliniske sygehistorie og objektive fund (se afsnit 4 for differentialdiagnoser). Inflammatoriske smerter i glutealregionen har i mange ?r v?ret betragtet som et v?sentligt symptom ved axSpA, men kan bl.a. ogs? ses hos patienter med osteitis consensans ilii og degenerativ rygsygdom. Tilstedev?relse af de axSpA associerede sygdomme psoriasis, inflammatorisk tarmsygdom, anterior uveitis og perifer artritis (fremh?vede i Tabel 3 og 4 nedenfor) ?ger sandsynligheden for at patienten har diagnosen axSpA, mens de ?vrige SpA karakteristika er mere usikre. Diagnosen axSpA/AS stilles optimalt i et lokalt forankret samarbejde mellem reumatologer, radiologer og evt. andre speciall?ger, s?rligt hos patienter hvor symptomer, kliniske fund og/eller den radiologiske beskrivelse er vanskelige at tolke. Dette mhp. at oparbejde og sikre en tilstr?kkelig ekspertise radiologisk og klinisk i tolkning af MR-billeder, kliniske oplysninger og fund. Diagnoserne axSpA og AS er alene ud fra de kliniske oplysninger beh?ftet med usikkerhed. Det er derfor vigtigt, at diagnoserne belyses ved MR/r?ntgenunders?gelse (RTG), under hensyntagen til den usikkerhed, der ogs? er ved disse unders?gelser. De p?viste MR-forandringer skal underst?tte de kliniske fund, og det skal vurderes, om et MR-fund underst?tter axSpA/AS diagnosen eller repr?senterer et tilf?ldigt fund, evt. associeret med andre smertegivende tilstande. Smerter, natlig opv?gning og stivhed i ryg og/eller gluteal region forekommer hyppigt ved andre tilstande (f.eks. degenerativ rygsygdom, Modic type I, diskus prolaps, HIZ-l?sion, osteitis condensans ilii og efter graviditet/postpartum. Forekomsten af degenerative tilstande i s?vel rygs?jle som SI-led stiger med alderenPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYXRvPC9BdXRob3I+PFllYXI+MjAyMDwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [6]. NBV-gruppen ?nsker at fremh?ve, at s?vel under- som overdiagnosticering er problematisk. Underdiagnosticering af axSpA er alvorlig hos helt unge patienter, hvor der erfaringsm?ssigt ofte kan ses aggressive kliniske sygdomsforl?b, som udvikler sig til AS. Samtidig er der en betydelig risiko for at overdiagnosticere axSpA, idet gruppen af patienter med enten inflammatorisk gluteal- / rygsmerte af anden ?rsag eller uspecifikke MR-fund antalsm?ssigt er langt st?rre end gruppen af patienter med axSpA/AS. Jo ?ldre patienten er, jo st?rre er risikoen for at fejltolke aldersrelaterede MR-forandringer i SI-led og rygs?jle.KlassifikationskriterierTabel 2 De modificerede New York Kriterier for ankyloserende spondylitisModificerede New York kriterier for AS ADDIN EN.CITE <EndNote><Cite><Author>van der Linden</Author><Year>1984</Year><RecNum>3547</RecNum><DisplayText>[1]</DisplayText><record><rec-number>3547</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184662">3547</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van der Linden, S.</author><author>Valkenburg, H. A.</author><author>Cats, A.</author></authors></contributors><titles><title>Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria</title><secondary-title>Arthritis and Rheumatism</secondary-title></titles><periodical><full-title>Arthritis and Rheumatism</full-title><abbr-1>Arthritis Rheum.</abbr-1><abbr-2>Arthritis Rheum</abbr-2><abbr-3>Arthritis &amp; Rheumatism</abbr-3></periodical><pages>361-368</pages><volume>27</volume><number>4</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Back Pain</keyword><keyword>HLA Antigens/genetics</keyword><keyword>Humans</keyword><keyword>New York</keyword><keyword>Rome</keyword><keyword>Spondylitis, Ankylosing/diagnosis/immunology/physiopathology</keyword></keywords><dates><year>1984</year></dates><pub-location>UNITED STATES</pub-location><isbn>0004-3591; 0004-3591</isbn><urls><related-urls><url>;[1]Klassifikations gradering:Definitiv AS:Opfyldelse af radiologisk kriterie og mindst ét klinisk kriterium (se nedenfor)Kliniske kriterier:L?ndesmerter og stivhed >3 m?neder, som bedres ved bev?gelse, men ikke ved hvileIndskr?nket bev?gelighed i l?nden* i frontal og sagittal planet Indskr?nket thorax ekspansion (gr?nsev?rdi > 5 cm)*: Gr?nsev?rdier i henhold til Bath Ankylosing Spondylitis (BAS)-skema fremkommer ved registrering i DANBIORadiologiske kriterier:Sakroiliitis > grad 2 bilateralt eller unilateralt > grad 3 eller 4 Sakroiliitis gradering:Grad 0: NormalGrad 1: Mistanke om forandringerGrad 2: Minimale forandringer – sm? lokaliserede omr?der med erosion eller sklerosering, uden bredde?ndring af ledspaltenGrad 3: Sikre forandringer: moderat eller avanceret sakroiliitis med en/flere af:ErosionerEvidens for skleroseringBredde?gning, forsn?vring eller delvis ankylose af ledspaltenGrad 4: Sv?re forandringer – total ankyloseTabel 3 ASAS Kriterierne for Axial SpondylartritisASAS kriterier til klassifikation af axSpA Hos patient med rygsmerter > 3 m?neder og < 45 ?r ved debutADDIN RW.CITE{{1322 Rudwaleit,M. 2009}}2Sakroiliitis p? r?ntgen eller MR +≥1 SpA karakteristikaELLERHLA-B27 + ≥2 yderligere SpA karakteristikaSpA karakteristika (som defineret nedenfor):Inflammatoriske smerter i glutealregion og/eller rygArtritis*Entesitis (h?l)Anterior uveitis* DaktylitisPositiv HLA-B27Psoriasis*Crohn?s sygdom/colitis ulcerosa*Godt respons p? NSAIDFamili?r dispositionForh?jet CRP *: tilstande med fremh?vet skrift ?ger sikkerheden for, at patienten har diagnosen axSpATabel 4 Definition af ASAS SpA karakteristika til klassifikation af axSpADefinition af ASAS SpA karakteristika til klassifikation af axSpAPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SdWR3YWxlaXQ8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFy

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ADDIN EN.CITE.DATA [2]SpA karakteristikaDefinitionSakroiliitis p? r?ntgenBilateral grad 2 eller unilateral grad 3-4, jf. de modificerede NY kriterier (Se ovenfor)Sakroiliitis p? MRAktiv inflammation i sakroiliakaleddene (SI-leddene) med definitivt knoglemarvs?dem/osteitis foreneligt med sakroiliitis ved SpA. Knoglemarvs?demet skal ift. ASAS v?re ”highly suggestive” for axSpA, hvilket ikke er klart defineret. I praksis g?lder, at ”jo mere knoglemarvs?dem jo bedre”. Ved samtidig tilstedev?relse af strukturelle l?sioner som erosioner, fedt, backfill og/eller intra-artikul?r ankylose ?ges den diagnostiske v?rdi PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW1iZXJ0PC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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ADDIN EN.CITE.DATA [7] Inflammatoriske rygsmerterFire af f?lgende fem parametre er til stede: 1) Debutalder <40 ?r 2) Snigende udvikling 3) Reduceres ved bev?gelse 4) Reduceres ikke ved hvile 5) Natlige smerter (med forbedring ved at st? op)Artritis*Aktuel eller tidligere aktiv synovitis diagnosticeret af l?geEntesitisH?l entesitis: Aktuel eller tidligere spontan smerte eller ?mhed ved unders?gelse af stedet for insertion af akillessene eller fascia plantaris p? calcaneusAnterior uveitis*Aktuel eller tidligere anterior uveitis diagnosticeret af ?jenl?geDaktylitisAktuel eller tidligere daktylitis diagnosticeret af l?gePositiv HLA-B27Positivt testresultat ved standard analyse. HLA-B27: Human leukocyt antigen subtype B27Psoriasis*Aktuel eller tidligere psoriasis diagnosticeret af l?geCrohn?s sygdom/colitis ulcerosa*Aktuel eller tidligere Crohns sygdom eller colitis ulcerosa diagnosticeret af l?geGodt respons p? NSAID 24-48 timer efter maksimal dosis af NSAID (non-steroid anti-inflammatorisk drug) er rygsmerterne v?k eller betydeligt reducerede Famili?r disposition Forekomst hos 1. eller 2. grads sl?gtninge af mindst en af: 1) Ankyloserende spondylitis2) Psoriasis 3) Uveitis 4) Reaktiv artritis 5) Inflammatorisk tarmsygdom (IBD)Forh?jet C-Reaktivt Protein (CRP)CRP over ?vre referencev?rdi ved rygsmerter efter udelukkelse af andre ?rsager til forh?jet CRP*: tilstande med fremh?vet skrift ?ger sikkerheden for, at patienten har diagnosen axSpASymptomerInflammatoriske rygsmerterDen inflammatoriske rygsmerte er et v?sentligt symptom ved axSpA/AS, men alene kan den ikke diskriminere mellem axSpA/AS og rygsmerter af mekanisk og degenerativ oprindelsePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Bcm5iYWs8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

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ZE5vdGU+AG==

ADDIN EN.CITE.DATA [8]. Smerterne er ofte lokaliseret til glutealregionen eller l?nden, men kan v?re lokaliseret til crista iliaca, trochanter regionerne eller str?lende ned bag p? femur. Patienten kan have sv?rt ved at lokalisere smerterne, som derfor kan fremtr?de som uspecifikke balle-/rygsmerter.AxSpA debuterer oftest n?r pt. er yngre end 45 ?r. Karakteristika for inflammatoriske glutealsmerter ved axSpASnigende udviklingVekslende sidelokalisation (alterende mellem h?jre og venstre balle) og/eller vekslende intensitet fra dag til dag og tidspunkt p? dagen.Bedring ved bev?gelse.Ingen bedring ved hvile. Patienten v?gner ofte i de tidligere morgentimer og m? st? op og g? omkring, hvorefter smerten igen aftager Morgenstivhed >30 minutters varighed.Ofte markant lindring af NSAID.Ekstra-aksiale symptomerH?velse, smerter og/eller stivhed i perifere led.Symptomer fra ?jne, gastro-instestinal kanal og/eller hud (se ASAS klassifikationskriterier).Smerter ved senef?ster (f.eks. h?l, crista iliaca og sternum).Tr?thed. Kliniske fund De kliniske fund kan omfatte en eller flere af nedenst?ende og skal v?re diagnosticeret af l?ge:Aksiale fundColumna og b?kken ADDIN EN.CITE <EndNote><Cite><Author>Kiltz</Author><Year>2015</Year><RecNum>1753</RecNum><DisplayText>[5]</DisplayText><record><rec-number>1753</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184516">1753</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Kiltz, U.</author><author>Baraliakos, X.</author><author>Borg, A. A.</author></authors><secondary-authors><author>Bijlsma, W. J.</author><author>Hachulla, E.</author><author>da Silva, J. A. P.</author><author>Doherty, M.</author><author>van Laar, J. M.</author><author>Cimmino, M. A.</author><author>Lioté, F.</author></secondary-authors></contributors><titles><title>Spondylarthropaties: Pathogenesis and Clinical Features</title><secondary-title>Textbook on Rheumatoc Diseases</secondary-title></titles><pages>295-318</pages><num-vols>Book, Section</num-vols><edition>Second</edition><dates><year>2015</year></dates><publisher>BMJ</publisher><urls></urls></record></Cite></EndNote>[5]: Direkte og indirekte ?mhed over SI-leddeneNedsat bev?gelighed i lumbal columna i frontalt og sagittalt planAffladet lordose i l?nd og cervicalt samt ?get kyfose thorakalt med fremadb?jet hoved og reduceret cervical rotation Thorax ekspansion: Nedsat (er afh?ngig af k?n og alder) Hofteled: ?mhed og indskr?nket bev?gelighedRyggens holdning og bev?gelighed kan v?re p?virket, men nedsat bev?gelighed kan ogs? ses ved andre rygsygdomme. Forandringer i columna ses ofte senere i forl?bet, da sygdommen hos de fleste patienter starter i SI-leddene og f?rst senere involverer columna. Ekstra-aksiale fundPerifer artritis?mhed og evt. h?velse ved enteser, oftest akillessenef?stet eller f?stet for fascia plantaris p? calcaneus eller f.eks. crista iliaca, sternum, albuer og kn?Anterior uveitisInflammation i tarmslimhinde herunder IBD Psoriasis (v?r s?rligt opm?rksom p? h?rbund, intertrigin?se omr?der og/eller negle) Daktylitis: Karakteristisk, men ikke specifik for axSpA (forekommer bl.a. ved psoriasisartritis, sarkoidose, artritis urica, mixed connective tissue disease, tuberkulose og syfilis) Differentialdiagnoser og mulige sameksisterende tilstandeDe vigtigste differentialdiagnoser udg?res af: Diskusdegeneration / Modic forandringerDiskusprolaps, ofte sent i forl?bet, hvor der er ballesmerte og ikke l?ngere smerter i benetGraviditetsbetingede forandringer PEVuZE5vdGU+PENpdGU+PEF1dGhvcj7DmHN0ZXJnYWFyZDwvQXV0aG9yPjxZZWFyPjIwMjA8L1ll

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PgB=

ADDIN EN.CITE.DATA [13-16]Holdningsanomalier i columna som skoliose og uens benl?ngde (disse ?ger risikoen for degenerative SI-leds forandringer med ?dem og evt. sklerosering; ved skoliose kan der ses knoglemarv?dem i den forreste del af hvirvellegemerne som indg?r i skoliosen)Spondylolistese / arkolyse (idiopatisk, eller f.eks. springgymnastik, dansere, atletik)Sygdomme/tilstande i hofteled f.eks. hofte impingement (CAM og Pincer l?sioner), hoftedysplasi, labrum-l?sioner og pr?artroseFacetleds artropatiMb. Scheuermann forandringerStressfrakturer i os sacrumInfektion i SI-led og rygs?jle har ofte et mere akut forl?b, ledsaget af sv?re smerter, febrilia og forh?jet CRPDiffus Idiopatisk Skeletal Hyperostose (DISH, Mb. Forestier)Tumorer i form af lymfom, sarkom og metastaserKronisk non-bakteriel osteitis (CNO) herunder SAPHO (Synovitis, Acne, Pustulosis palmoplantaris, Hyperostose Osteitis (foci specielt i brystkassens forreste del og columna)) og CRMO (chronisc recurrent multifocal osteomyelitis).Sygdomme i organer i b?kken og abdomen.Knoglemarv?dem forekommer ikke kun ved axSpA/AS, men kan ogs? ses ved ovenst?ende tilstande, hvor der bl.a. er observeret knoglemarvs?dem ved SI-leddene hos 21-27% af patienter med degenerativ rygsygdomPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XZWJlcjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [20] af 18-45 ?rige havde forandringer ved SI-leddene, og i columna totalis fandtes ≥1 hj?rnel?sion med knoglemarvs?dem hos 27.5% og ≥1 fedt hj?rnel?sion hos 81% og ≥5 hos 23%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXJhbGlha29zPC9BdXRob3I+PFllYXI+MjAyMDwvWWVh

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ADDIN EN.CITE.DATA [20]. Patienter med axSpA/AS kan ogs? have/udvikle disse forandringer parallelt med deres axSpA/AS forandringer. Overvejelser vedr?rende samtidig forekomst af disse tilstande er is?r vigtigt hos ?ldre patienter som udredes for axSpA, og hos ?ldre patienter med kendt axSpA/AS, hvor degenerative og belastningsrelaterede tilstande er hyppigt forekommende, men de kan ogs? ses hos helt unge. Hos kvinder kan der 1-2 ?r post partumPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2JhbGxhaDwvQXV0aG9yPjxZZWFyPjIwMjA8L1llYXI+

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ADDIN EN.CITE.DATA [11, 15]) og symfysen, og patienterne kan have s?vel inflammatoriske som belastningsrelaterede smerter i balle/b?kken. Tilsvarende MR-forandringer kan ses hos kvinder post-partum uden samtidige smerter (op til 21%)PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TZXZlbjwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl

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bmROb3RlPn==

ADDIN EN.CITE.DATA [21, 22]. Endelig kan der hos meget fysisk aktive personer, som f.eks. l?bere (herunder fodboldspillere), ishockeyspillere og v?rnepligtige, hyppigt p?vises knoglemarvs?dem ved SI-led (op til 40% PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XZWJlcjwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [20]Normale varianter ved SI-led, f.eks. accessoriske led, recesser, meget uregelm?ssige ledflader mm. ADDIN EN.CITE <EndNote><Cite><Author>Umay</Author><Year>2020</Year><RecNum>4467</RecNum><DisplayText>[23]</DisplayText><record><rec-number>4467</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1601297029">4467</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Umay, S. T.</author><author>Korkmaz, M.</author></authors></contributors><titles><title>Frequency of anatomical variation of the sacroiliac joint in asymptomatic young adults and its relationship with sacroiliac joint degeneration</title><secondary-title>Clinical anatomy</secondary-title></titles><periodical><full-title>Clinical Anatomy</full-title><abbr-1>Clin. Anat.</abbr-1><abbr-2>Clin Anat</abbr-2></periodical><pages>839-843</pages><volume>33</volume><section>839</section><dates><year>2020</year></dates><urls></urls></record></Cite></EndNote>[23]Lumbosakral overgangshvirvel (ved de asymmetriske typer kan ses ?dem ved selve artikulationen, men ogs? i andre dele af SI-leddene)H?matopoietisk aktiv knoglemarv, som kan simulere sakroiliitis hos helt ungeHyper-parathyreoidisme (prim?r/sekund?r)Diagnostiske overvejelser og konklusionDen optimale vurdering af om en patient har axSpA/AS, en anden sygdom/tilstand (differentialdiagnose) eller om MR-forandringer er et tilf?ldigt fund foruds?tter grundig anamnese og objektiv unders?gelse. Ved anamnesen fokuseres p? smerteanamnese, SpA-karakteristika, samt oplysninger om f?dsler og fysisk aktivitet/sport i fritid/arbejde. Ved den objektive unders?gelse specielt fokus p? ryg, SI-led, hofteled, perifere led og enteser og ?vrige SpA-karakteristika.I diagnose / konklusionen anf?res pr?misserne for axSpA/AS diagnosen. Samtidige overvejelser, der er gjort ift. evt. differentialdiagnoser anf?res. Det er desuden vigtigt at anf?re information givet til patienten, s?rligt i de tilf?lde hvor der foreligger diffentialdiagnostiske overvejelser. Patienter, hvor axSpA diagnosen ikke bekr?ftes, afsluttes til prim?rsektoren eller henvises til andet relevant l?geligt speciale.Henvisning og visitation Patienter kan henvises til vurdering af mulig axSpA ved:Inflammatoriske ryg- og /eller ballesmerter af > 3 m?neders varighedAlder ≤ 45 ?r ved debut af ryg- og / eller ballesmerterMistanke om axSpAVed henvisningen skal der, ud over afdelingens s?dvanlige anbefalinger, foreligge:Oplysning om patienten har psoriasis, inflammatorisk tarmsygdom og/eller anterior uveitisCRPR?ntgen af columna lumbalis og SI-led ved symptomvarighed >5 ?rOm muligt HLA-B27 MR-skanning inden henvisningen anbefales ikke, med mindre skanningen er lavet jf. de tekniske specifikationer i denne NBV.BilleddiagnostikFlowdiagram for udredningMR af SI-led b?r udf?res ved klinisk mistanke om axSpA/AS, men b?r ikke rutinem?ssigt udf?res som led i MR af columna hos patienter med uspecifikke l?nde-rygsmerter eller mistanke om andre rygsygdomme, hvor der er minimal/ingen klinisk mistanke om axSpA/AS. Ved patienter > 45 ?r b?r der udvises tilbageholdenhed med MR af SI-led pga. hyppig forekomst af degenerativ lidelse.Figur 1 Flow diagram for udredning af patienter mist?nkt for axSpA/ASDefinitioner p? sakroiliitis ved axSpA/AS p? MR-skanning og RTGP? MR-skanning defineres sakroiliitis ved axSpA/AS som inflammation (knoglemarvs?dem) subkondralt, der er ”highly suggestive for” SpAPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW1iZXJ0PC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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ADDIN EN.CITE.DATA [24]. Dette betyder i praksis sikker tilstedev?relse af knoglemarvs?dem samt, at differentialdiagnoser som knoglemarvs?dem ved belastnings- og graviditetsbetingede forandringer, stress fraktur mm. kan udelukkes (se afsnit 4). Hvis det i praksis er vanskeligt at afg?re om et knoglemarvs?dem er ”highly suggestive for” SpA kan afg?relsen st?ttes af evt. ledsagende strukturelle forandringer, specielt erosionerPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW1iZXJ0PC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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RW5kTm90ZT5=

ADDIN EN.CITE.DATA [24], men uden knoglemarvs?dem vil tilstedev?relsen af erosioner, fedtinfiltration, sklerose eller ankylose ikke opfylde ASAS kriterierne for ”aktiv sacroiliit”PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW1iZXJ0PC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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ADDIN EN.CITE.DATA [25] anf?rer, at udvalgte kroniske forandringer (specielt erosioner) p? MR-skanning af SI-led uden samtidig tilstedev?relse af inflammation ogs? har diagnostisk v?rdi ift. diagnostik af axSpAPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYW5kbDwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [25]. Ved konventionel RTG unders?gelse defineres sakroiliitis iht. de modificerede NY kriterier ADDIN EN.CITE <EndNote><Cite><Author>van der Linden</Author><Year>1984</Year><RecNum>3547</RecNum><DisplayText>[1]</DisplayText><record><rec-number>3547</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184662">3547</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van der Linden, S.</author><author>Valkenburg, H. A.</author><author>Cats, A.</author></authors></contributors><titles><title>Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria</title><secondary-title>Arthritis and Rheumatism</secondary-title></titles><periodical><full-title>Arthritis and Rheumatism</full-title><abbr-1>Arthritis Rheum.</abbr-1><abbr-2>Arthritis Rheum</abbr-2><abbr-3>Arthritis &amp; Rheumatism</abbr-3></periodical><pages>361-368</pages><volume>27</volume><number>4</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Back Pain</keyword><keyword>HLA Antigens/genetics</keyword><keyword>Humans</keyword><keyword>New York</keyword><keyword>Rome</keyword><keyword>Spondylitis, Ankylosing/diagnosis/immunology/physiopathology</keyword></keywords><dates><year>1984</year></dates><pub-location>UNITED STATES</pub-location><isbn>0004-3591; 0004-3591</isbn><urls><related-urls><url>;[1]. Der er stor usikkerhed, selv blandt radiologiske SpA eksperter, vedr. tolkning af r?ntgen af SI-led, hvorfor kun meget udtalte forandringer forenelig med AS, som sv?re erosioner og udtalt ankylose, b?r till?gges diagnostisk v?rdiPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaHJpc3RpYW5zZW48L0F1dGhvcj48WWVhcj4yMDE3PC9Z

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ADDIN EN.CITE.DATA [26]. En smal ledspalte er ikke et sikkert tegn p? sacroiliit, da det ogs? ses ved degenerative forandringer. Ved samtidig MR-skanning af SI-led uden karakteristiske subkondrale knoglemarvsforandringer er det yderst sj?ldent, at en patient med ledspalteafsmalning har axSpAPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaHJpc3RpYW5zZW48L0F1dGhvcj48WWVhcj4yMDE3PC9Z

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ADDIN EN.CITE.DATA [26].Patienter med normale SI-led ved RTG og MR-skanning kan tildeles diagnosen axSpA, hvis RTG af columna lumbalis og/eller cervicalis viser karakteristiske axSpA forandringer i form af squaring af hvirvelcorpora (med tegn p? knoglenydannelse langs forfladen af hvirvlerne), syndesmofytter, parasyndesmofytter, erosioner mm. MR-p?vist knoglemarv?dem ved flere costovertebral-led, costotransversal-led og/eller adskillige facetled kan have diagnostisk v?rdi ift. axSpA/AS, mens den diagnostiske v?rdi af MR-p?vist knoglemmarv?dem og/eller fedt ved hj?rnerne af hvirvellegemerne og langs endepladerne har langt mindre diagnostik v?rdi, da de forekommer hyppigt med stigende alder. Desuden foruds?ttes det at differentialdiagnoser s?som diskusdegenerative forandringer med knoglemarvsforandringer (Modic type 1 og 2), smertegivende lumbosacral overgangshvirvel med mekanisk betinget ?dem m.m. er udelukket (se afsnit 4).Beskrivelse af billeddiagnostiske unders?gelserMR-skanningVed beskrivelse af MR-skanning af s?vel SI-leddene som columna skal angives hvilke sekvenser og snitretninger, der danner basis for billedvurderingen.For SI-leddenes vedkommende er det vigtigt at beskrive graden og lokalisationen af evt. knoglemarvs?dem, da ?demet ved axSpA/AS ofte er lokaliseret anderledes end ved f.eks. belastnings- og graviditetsbetingede forandringer. Tilstedev?relse eller frav?r af ledsagende strukturelle forandringer i form af erosioner, fedtinfiltration, backfill og ankylose og deres sv?rhedsgrad beskrives.Forandringer i columna beskrives p? samme m?de med fokus p? aktive inflammatoriske og strukturelle forandringer, med ledsagende beskrivelse af evt. samtidige degenerative forandringer. MR-beskrivelsen afsluttes om muligt med en definitiv konklusion vedr. tilstedev?relse eller frav?r af typiske tegn p? axSpA/AS. Der er aktuelt stor forskningsaktivitet vedr. MR-fund ved axSpA/AS og relevante differentialdiagnose. Ved interesse se venligst afsnit 14.2 vedr. aktuel forskningsbaseret viden, der har klinisk betydning.R?ntgenunders?gelserVed beskrivelse af RTG af SI-leddene anbefales det at angive graden af evt. forandringer jf. NY kriterierne mhp. om patienten opfylder kriterierne for AS. Ligeledes er det vigtigt at beskrive, om der er andre typer af forandringer, f.eks. lumbo-sacral overgangshvirvel.Ved beskrivelse af RTG af columna lumbalis og columna cervicalis skal n?vnes tilstedev?relse eller frav?r af typiske tegn p? axSpA/AS i form af squaring af hvirvelkorpora, sklerosering sv.t. til hvirvelhj?rnerne, syndesmofytter og/eller paravertebral knoglenydannelse. Ligesom det beskrives, om der er andre typer af forandringer jfr. afsnit om differentialdiagnoser (se pkt. 4). RTG-beskrivelsen afsluttes om muligt med en definitiv konklusion vedr. tilstedev?relse eller frav?r af typiske AS/axSpA forandringer. Knogleskintigrafi Knogleskintigrafi har ingen plads i diagnostikken af axSpA/AS PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYW5kbDwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [25].Ved frakturmistanke Idet frakturer kan v?re livstruende ADDIN EN.CITE <EndNote><Cite><Author>Wysham</Author><Year>2017</Year><RecNum>3781</RecNum><DisplayText>[27]</DisplayText><record><rec-number>3781</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184679">3781</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wysham, K. D.</author><author>Murray, S. G.</author><author>Hills, N.</author><author>Yelin, E.</author><author>Gensler, L. S.</author></authors></contributors><auth-address>University of California, San Francisco.; University of California, San Francisco.; University of California, San Francisco.; University of California, San Francisco.; University of California, San Francisco.</auth-address><titles><title>Cervical Spinal Fracture and Other Diagnoses Associated With Mortality in Hospitalized Ankylosing Spondylitis Patients</title><secondary-title>Arthritis care &amp; research</secondary-title></titles><periodical><full-title>Arthritis Care &amp; Research</full-title><abbr-1>Arthritis Care Res. (Hoboken)</abbr-1><abbr-2>Arthritis Care Res (Hoboken)</abbr-2></periodical><pages>271-277</pages><volume>69</volume><number>2</number><dates><year>2017</year></dates><pub-location>United States</pub-location><publisher>American College of Rheumatology</publisher><isbn>2151-4658; 2151-464X</isbn><urls></urls><electronic-resource-num>10.1002/acr.22934 [doi]</electronic-resource-num><access-date>Feb</access-date></record></Cite></EndNote>[27], er det vigtigt, at der udarbejdes en hurtig udredningsplan i samarbejde med den ansvarlige radiolog.Akut RTG er obligat ved mistanke om fraktur (akutte smerter, som ikke ligner de typiske inflammatoriske smerter).Ved negativt RTG skal der laves supplerende CT-skanning, som er mere sensitiv til p?visning af frakturer.MR-skanning er altid indiceret ved ledsagende neurologiske symptomer og er et naturligt supplement til CT-skanning, idet unders?gelsen kan visualisere medulla spinalis og bl?ddelsl?sioner, inkl. epidurale h?matomer ADDIN EN.CITE <EndNote><Cite><Author>Werner</Author><Year>2016</Year><RecNum>3738</RecNum><DisplayText>[28]</DisplayText><record><rec-number>3738</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184676">3738</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Werner, B. C.</author><author>Samartzis, D.</author><author>Shen, F. H.</author></authors></contributors><auth-address>From the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Werner and Dr. Shen), and the Department of Orthopaedics and Traumatology, University of Hong Kong, Pok Fu Lam, Hong Kong (Dr. Samartzis).</auth-address><titles><title>Spinal Fractures in Patients With Ankylosing Spondylitis: Etiology, Diagnosis, and Management</title><secondary-title>The Journal of the American Academy of Orthopaedic Surgeons</secondary-title></titles><pages>241-249</pages><volume>24</volume><number>4</number><keywords><keyword>Biomechanical Phenomena</keyword><keyword>Cervical Vertebrae/diagnostic imaging/surgery</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae/diagnostic imaging/surgery</keyword><keyword>Spinal Fractures/diagnosis/etiology/physiopathology/therapy</keyword><keyword>Spondylitis, Ankylosing/complications/physiopathology</keyword><keyword>Thoracic Vertebrae/diagnostic imaging/surgery</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2016</year></dates><pub-location>United States</pub-location><isbn>1940-5480; 1067-151X</isbn><urls></urls><electronic-resource-num>10.5435/JAAOS-D-14-00149 [doi]</electronic-resource-num><access-date>Apr</access-date></record></Cite></EndNote>[28].Opf?lgning og monitoreringKlinisk opf?lgningVed kontrol af axSpA/AS indg?r f?lgendeADDIN RW.CITE{{922 Braun,J. 2006; 4729 vanderHeijde,D. 2011; 4759 vanderHeijde,D. 2017}}PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcmF1bjwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [29-31]:Sygdomsaktivitet: Ankylosing Spondylitis Disease Activity?Score (ASDAS) eller The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; aktivitetsm?l, rapporteret af patienten); CRP, perifere led og enteserFunktionsniveau: The Bath Ankylosing Spondylitis Disease Function Index (BASFI; funktionsm?l, rapporteret af patienten), The Bath Ankylosing Spondylitis Disease Metrology Index (BASMI; objektivt m?l for sygdommens sv?rhedsgrad ved l?geunders?gelse) samt i forhold til familie, hjem og arbejde/studierKomorbiditeter: ekstra-artikul?re SpA manifestationer, osteoporose og kardiovaskul?re forholdBivirkninger til behandlingHvor hyppigt en patient b?r ses og vurderes vil v?re individuelt bestemtPatienter med etableret diagnose, som f?lges i afdelingen, anbefales vurderet mindst en gang per kalender?rPatienter med st?rre behov for vurdering/konsultation:Ny diagnosticerede patienter Patienter med h?j sygdomsaktivitetMR af SI-led og columna totalis mhp. opf?lgningVed overvejelse af biologisk behandling eller skift til ny biologisk behandling. Ved muligt behandlingssvigt anbefales ny MR efter minimum 6 m?neder s?ledes der foreligger en vurdering af inflammationen inden den ?ndrede behandling.RTG mhp. monitorering af strukturelle forandringer, jf. afsnittet ”Diagnostik”.BehandlingBehandling af axSpA/AS sker p? baggrund af en f?lles beslutningsproces mellem patient og l?ge, hvor der aftales et realistisk behandlingsm?l, som l?bende kan justeres afh?ngig af behandlingsresultater og muligheder.Fire internationale retningslinjer fra ASAS omfatter behandling af patienter med axSpA/ASPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcmF1bjwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [31, 33, 34]Information til patienten og p?r?rendeInformation tilbydes individuelt eller p? hold. Informationen omfatter sygdommens natur, mulige komorbiditeter, anbefaling af rygeoph?r, v?gttab, behandling og prognose.Herudover gives vejledning omkring sociale forhold ift. uddannelse, tilknytning til arbejdsmarkedet samt mulighed for evt. hj?lpemidlerTr?ningsterapi Alle SpA-patienter anbefales p? diagnosetidspunktet selv at tr?ne fremadrettet (optimalt efter vejledning fra fysioterapeut).Den kliniske erfaring er, at mange patienter har god effekt af regelm?ssig fysisk tr?ning i forhold til smerter i bev?geapparatet, s?vel balle-, ryg-, led- som entesesmerter samt vedligeholde / forbedre bev?geligheden.Aktiv tr?ning skal prioriteres overfor passiv behandlingADDIN RW.CITE{{4735 Dagfinrud,H. 2008; 4728 Millner,J.R. 2016}}PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYWdmaW5ydWQ8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFy

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ADDIN EN.CITE.DATA [35, 36] og tr?ningen justeres afh?ngig af funktionsniveau og sygdomsaktivitet.S?fremt patientens sygdom giver begr?nsninger i forhold til tr?ning henvises til fysioterapeutisk vejledning.Regelm?ssig superviseret holdtr?ning eller regelm?ssig periodevis superviseret individuel tr?ning har en bedre effekt p? at bevare bev?geligheden end hjemmetr?ning uden supervision og opf?lgning. Vederlagsfri fysioterapiHoldtr?ningAS patienter kan modtage vederlagsfri fysioterapi i form af holdtr?ning.Individuel tr?ningPatienter med et sv?rt fysisk* handikap kan henvises til individuel tr?ning.Hvis en AS patient ikke har et sv?rt fysisk handicap, men l?ge og fysioterapeut vurderer, at der er behov for individuel fysioterapi, som supplement eller i stedet for holdtr?ning, udfylder fysioterapeuten blanketten ”Undtagelsesredeg?relse”, som efterf?lgende underskrives af l?gen.De g?ldende regler giver AS patienter, men ikke axSpA patienter, adgang til vederlagsfri fysioterapi. AxSpA patienter kan overvejes henvist til fysioterapi i prim?rsektoren med egenbetaling. Alternativt kan der ved funktionstab henvises med en genoptr?ningsplan (GOP) til kommunal genoptr?ning.*En patient, der kan klare sig selv indend?rs i d?gnets 24 timer uden hj?lp eller hj?lpemidler til den daglige personlige livsf?relse, har ikke et sv?rt fysisk handikap.NSAIDNSAID anbefales som f?rstevalgs behandling ved axSpA og AS ved smerter og stivhed. Der anbefales fast daglig behandling ved vedvarende aktiv, symptomgivende sygdom. Ved remission kan dosis fors?ges reduceret og hvis muligt seponeret. Ved ordination af NSAID v?lges pr?parat og dosering ud fra:Evt. tidligere anvendte pr?parater og doseringKardio-vaskul?re, gastro-intestinale og renale risikofaktorerPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcmF1bjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [33]Der kombineres med syrepumpeh?mmer, hvis der er gastro-intestinale risikofaktorer ADDIN EN.CITE <EndNote><Cite><Author>Pfeiffer-Jensen</Author><RecNum>2578</RecNum><DisplayText>[37]</DisplayText><record><rec-number>2578</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184584">2578</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Pfeiffer-Jensen, M.</author><author>Stauning, J. A.</author><author>Stengaard-Pedersen, K.</author></authors></contributors><titles><title>NSAID</title></titles><dates></dates><urls><related-urls><url>;[37]Et Cochrane review viser ingen forskel i effekt mellem forskellige NSAIDPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [38]. Ved sammenligning af NSAID med placebo findes der ikke en ?get bivirkningsfrekvens ved kortvarig behandling (6-12 uger)PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [38, 39]. Jfr. Sundhedsstyrelsen, Institut for Rationel Farmakoterapi ADDIN EN.CITE <EndNote><Cite><Author>Pfeiffer-Jensen</Author><RecNum>2578</RecNum><DisplayText>[37]</DisplayText><record><rec-number>2578</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184584">2578</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Pfeiffer-Jensen, M.</author><author>Stauning, J. A.</author><author>Stengaard-Pedersen, K.</author></authors></contributors><titles><title>NSAID</title></titles><dates></dates><urls><related-urls><url>;[37], anbefales ibuprofen eller naproxen. Der ydes generelt tilskud fra Sygesikringen til ibuprofen, naproxen og dexibuprofen.Tabel 5 Oversigt over NSAIDPr?paratFormAnbefalet d?gndosisFordelingMaksimal d?gndosisIbuprofenTablet Depottablet1200-1800 mg800 -1600 mgFordelt p? 3-4 doser1 dosis til natten (evt. fordelt p? 2 doser)2400 mg i maksimalt 4-6 ugerNaproxenTablet1000 mgFordelt p? 2 doser1000 mgEfter mindst 2 ugers behandling vurderes effekten og ved utilstr?kkelig effekt skiftes til andet pr?parat med ny vurdering efter yderligere mindst 2 uger ADDIN EN.CITE <EndNote><Cite><Author>van der Heijde</Author><Year>2011</Year><RecNum>3489</RecNum><DisplayText>[30]</DisplayText><record><rec-number>3489</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184659">3489</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van der Heijde, D.</author><author>Sieper, J.</author><author>Maksymowych, W. P.</author><author>Dougados, M.</author><author>Burgos-Vargas, R.</author><author>Landewe, R.</author><author>Rudwaleit, M.</author><author>Braun, J.</author><author>Assessment of SpondyloArthritis international, Society</author></authors></contributors><auth-address>Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands. d.vanderheijde@kpnplanet.nl</auth-address><titles><title>2010 Update of the international ASAS recommendations for the use of anti-TNF agents in patients with axial spondyloarthritis</title><secondary-title>Annals of the Rheumatic Diseases</secondary-title></titles><periodical><full-title>Annals of the Rheumatic Diseases</full-title><abbr-1>Ann. Rheum. Dis.</abbr-1><abbr-2>Ann Rheum Dis</abbr-2></periodical><pages>905-908</pages><volume>70</volume><number>6</number><keywords><keyword>Antirheumatic Agents/contraindications/therapeutic use</keyword><keyword>Humans</keyword><keyword>International Cooperation</keyword><keyword>Practice Guidelines as Topic</keyword><keyword>Spondylarthritis/classification/diagnosis/drug therapy</keyword><keyword>Spondylitis, Ankylosing/drug therapy</keyword><keyword>Treatment Outcome</keyword><keyword>Tumor Necrosis Factor-alpha/antagonists &amp; inhibitors</keyword></keywords><dates><year>2011</year></dates><pub-location>England</pub-location><isbn>1468-2060; 0003-4967</isbn><urls></urls><electronic-resource-num>10.1136/ard.2011.151563; 10.1136/ard.2011.151563</electronic-resource-num><access-date>Jun</access-date></record></Cite></EndNote>[30]. Hos patienter, hvor der ses effekt af NSAID, ses yderligere respons frem til uge 28PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaWVwZXI8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [31]. S?fremt biologisk behandling er kontra-indiceret kan Salazopyrin behandling overvejes ogs? ved aksial sygdom, men der foreligger ikke evidens for dette.Glukokortikoid Lokal injektionsbehandling kan gives ved behov ved perifer artritis, entesitis og eventuelt ved sakroiliit. Vedvarende systemisk glukokortikoid har ingen plads ved behandling af aksial sygdom. Biologiske l?gemidler (bDMARD) ASDAS ≥ 2,1 ADDIN EN.CITE <EndNote><Cite><Author>Lukas</Author><Year>2009</Year><RecNum>2088</RecNum><DisplayText>[41]</DisplayText><record><rec-number>2088</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184549">2088</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lukas, C.</author><author>Landewe, R.</author><author>Sieper, J.</author><author>Dougados, M.</author><author>Davis, J.</author><author>Braun, J.</author><author>van der Linden, S.</author><author>van der Heijde, D.</author><author>Assessment of SpondyloArthritis international, Society</author></authors></contributors><auth-address>University Hospital and CAPHRI Research Institute, Maastricht 6202 AZ, The Netherlands.</auth-address><titles><title>Development of an ASAS-endorsed disease activity score (ASDAS) in patients with ankylosing spondylitis</title><secondary-title>Annals of the Rheumatic Diseases</secondary-title></titles><periodical><full-title>Annals of the Rheumatic Diseases</full-title><abbr-1>Ann. Rheum. Dis.</abbr-1><abbr-2>Ann Rheum Dis</abbr-2></periodical><pages>18-24</pages><volume>68</volume><number>1</number><keywords><keyword>Back Pain/physiopathology</keyword><keyword>Blood Sedimentation</keyword><keyword>C-Reactive Protein/analysis</keyword><keyword>Chronic Disease</keyword><keyword>Delphi Technique</keyword><keyword>Disability Evaluation</keyword><keyword>Discriminant Analysis</keyword><keyword>Humans</keyword><keyword>Principal Component Analysis</keyword><keyword>Regression Analysis</keyword><keyword>Severity of Illness Index</keyword><keyword>Spondylitis, Ankylosing/blood/physiopathology</keyword></keywords><dates><year>2009</year></dates><pub-location>England</pub-location><isbn>1468-2060; 0003-4967</isbn><urls></urls><electronic-resource-num>10.1136/ard.2008.094870 [doi]</electronic-resource-num><access-date>Jan</access-date></record></Cite></EndNote>[41] eller BASDAI ≥ 40 ADDIN EN.CITE <EndNote><Cite><Author>Garrett</Author><Year>1994</Year><RecNum>1236</RecNum><DisplayText>[42]</DisplayText><record><rec-number>1236</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1537184487">1236</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Garrett, S.</author><author>Jenkinson, T.</author><author>Kennedy, L. G.</author><author>Whitelock, H.</author><author>Gaisford, P.</author><author>Calin, A.</author></authors></contributors><auth-address>Royal National Hospital for Rheumatic Diseases, Bath, UK.</auth-address><titles><title>A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index</title><secondary-title>The Journal of rheumatology</secondary-title></titles><pages>2286-2291</pages><volume>21</volume><number>12</number><keywords><keyword>Data Interpretation, Statistical</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain/physiopathology</keyword><keyword>Physical Therapy Modalities</keyword><keyword>Reproducibility of Results</keyword><keyword>Severity of Illness Index</keyword><keyword>Spondylitis, Ankylosing/physiopathology/therapy</keyword><keyword>Surveys and Questionnaires</keyword></keywords><dates><year>1994</year></dates><pub-location>Canada</pub-location><isbn>0315-162X; 0315-162X</isbn><urls></urls><access-date>Dec</access-date></record></Cite></EndNote>[42] ved gentagne m?linger med minimum en m?neds interval, kan v?re udtryk for betydelig sygdomsaktivitet, og b?r medf?re vurdering p? ekspertniveau med henblik p? at udelukke andre ?rsager til rygsmerter og/eller forh?jet CRP.Indikation for behandling med bDMARDS?fremt der ikke er tilfredsstillende dokumenteret effekt af tr?ning og NSAID-behandling i maksimal tolererede/rekommanderede doser med minimum to pr?parater inden for minimum 4 uger, og andre ?rsager til manglende behandlingseffekt er udelukket, kan patienten vurderes mhp. bDMARD behandling. F?lgende krav skal v?re opfyldt inden bDMARD behandling jfr. ASAS rekommandationPEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGVyIEhlaWpkZTwvQXV0aG9yPjxZZWFyPjIwMTc8

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ADDIN EN.CITE.DATA [31]:Diagnosen axSpA/AS skal v?re stillet jf. afsnittet ”Diagnose”Det anbefales, at der ved behandlingsstart foreligger: MR-skanning, ikke ?ldre end 6-12 m?neder med p?vist inflammation forenelig med axSpARTG mhp. status ift. om NY kriterierne er opfyldtCRP-m?lingDokumenteret vedvarende (>4 uger) ASDAS ≥ 2,1 eller BASDAI score ≥ 40 (med v?gten lagt p? sp?rgsm?l 5 og 6, som prim?rt p?virkes af den inflammatoriske komponent). Det skal i journalen noteres om pt. f?lges med ASDAS eller BASDAI.Beslutningen om start af biologisk behandling beror p? en konferencebeslutning mellem speciall?ger i reumatologi, hvor eventuelle kontraindikationer tages i betragtning.Pr?diktorer for effekt af behandling med TNFα-h?mmerF?lgende forhold kan inddrages i vurderingen f?r start af behandling med antistof rettet mod tumor nekrotiserende faktor alfa (TNFα-h?mmer):Parametre der taler FOR effekt af TNFα-h?mmer behandling:Inflammatorisk aktivitet p?vist p? MR-skanningForh?jet CRPKort sygdomsvarighedPositiv HLA-B27 Parametre der taler IMOD effekt af TNFα-h?mmer behandling:Negativ HLA-B27Normalt CRPH?j BASFIDer foreligger endnu ikke studier af pr?diktorer for effekt/ikke-effekt af andre bDMARD end TNFα-h?mmer.Valg af bDMARDDer er evidens for effekt af TNFα-h?mmer ved axSpA/AS samt for antistof mod interleukin-17 (IL-17 h?mmer) ved axSpA og AS. P? nuv?rende tidspunkt er f?rstevalg ved axSpA/AS TNFα-h?mmer jf. Medicinr?det.Patientens komorbiditet kan p?virke valg af pr?parat. Ved forekomst af flere sygdomme, der kr?ver biologisk behandling (psoriasis, Mb. Crohn/colitis ulcerosa, anterior uveit) v?lges det pr?parat/den dosis, der d?kker disse. Ved anterior uveit eller inflammatorisk tarmsygdom v?lges TNFα-h?mmer. Der henvises til gennemgang af l?gemiddelrekommendation fra Medicinr?det (tidligere RADS) vedr?rende valg af pr?parat og dosering. Vurdering af behandlingsresponsEkspertvurderingReduktion i ASDAS ≥ 1,1 eller BASDAI ≥ 20 Ved behandlingssvigt b?r det overvejes om diagnosen er korrektVed tegn til manglende effekt af behandlingen ny MR-skanning, s?fremt det er mere end 6-12 m?neder siden sidste skanning. Dette er is?r vigtigt ved ny-diagnosticerede patienter for at sikre, at diagnosen er korrekt.Maksimal klinisk effekt forventes f?rst indtr?dt efter 3-4 m?neder.BehandlingsskiftEr behandlingsrespons ikke opn?et iht. til ovenst?ende efter 3-4 m?neders behandling, b?r diagnosen genovervejes og behandlingen revurderes mhp. seponering eller skift til anden behandling. Inden skift af biologisk behandling foretages efter individuel vurdering:MR af SI-led og columna totalis, s?fremt disse er foretaget for > 6 mdr. sidenRTG: Liggende AP af pelvis* og columna lumbalis i 2 planer s?fremt disse er mere end to ?r gamle*S?fremt pt. opfylder de radiografiske kriterier for AS, skal RTG af pelvis kun gentages hvis en evt. progression har behandlingsm?ssig betydning. Dosisreduktion og/eller seponering ved remissionI frav?r af robust evidens m? regels?t for dosisreduktion og seponering af farmakologisk behandling ved opn?et remission opfattes som pragmatisk. Der foreg?r aktuelt flere steder i Danmark dosisreduktion studier. Resultaterne af disse afventes.Hyppige problemstillinger under behandlingInfektionerPausér behandling til infektionen er velbehandlet (fraset f.eks. mindre og ukomplicerede infektioner som en let fork?lelse, lokaliseret urinvejsinfektion hos kvinder eller lokaliseret hudinfektion)Paradoks psoriasisVurdering ved dermatolog. Overveje till?g af methotrexat alternativt skift til anden behandlingsmodalitet i samr?d med dermatologOperation Elektive operationer planl?gges mindst ét doseringsinterval efter den sidst givne dosisBehandlingen kan genoptages ved sikker s?rheling uden tegn til infektionVaccinationer Der henvises til NBV vedr. dette LINK.GraviditetDer henvises til Medicinr?dets vejledning samt NBV vedr. dette LINKKirurgi Indikationer for kirurgisk intervention, der udf?res p? h?jtspecialiseret niveau: Invaliderende kyfoseUstabile columna frakturerIndstilling til hofte/kn? alloplastik f?lger samme retningslinjer, som for patienter uden SpADANBIO registreringDANBIO modulet ”Rygs?jlegigt” anvendes som monitoreringsv?rkt?j og sikrer, at patienterne monitoreres iht. ”Kvalitetsindikatorerne”.Tabel 6 DANBIO kvalitetsindikatorer IndikatorBeskrivelse og Standard1. Ny-diagnosticerede axSpA patienter skal f?lges med t?t kontrolNy-diagnosticerede axSpA patienter skal registreres med CRP, sygdomsaktivitet (BASDAI og/eller ASDAS), funktionsniveau (BASFI) og medicinsk behandling mindst 2 gange og bev?gelighed (BASMI) mindst en gang det f?rste sygdoms?r.Ved oprettelse (baseline) i DANBIO registreres diagnosetidspunkt og diagnose. Standard: Min. 90% 2. Ny-diagnosticerede axSpA patienter skal v?re unders?gt for HLA-B27 samt billeddiagnostisk p? diagnosetidspunktetNy-diagnosticerede axSpA patienter skal registreres med HLA-B27, MR-skanning og/eller r?ntgen status (SI-led og columna lumbalis) p? diagnosetidspunktet (+/- 6 mdr.).Standard: Min. 90% 3. Patienter med axSpA skal f?lges longitudinelt med sygdomsaktivitet, funktionsniveau og angivelse af medicinsk behandling.Patienter med axSpA med sygdomsvarighed > 1 ?r skal registreres mindst 1 gang ?rligt med CRP, sygdomsaktivitet (BASDAI og/eller ASDAS), funktionsniveau (BASFI) og angivelse af medicinsk behandling.Standard: Min. 90% KomplikationerOsteoporoseFlere studier har dokumenteret, at patienter med AS har en v?sentlig ?get risiko for osteporose og spinale sammenfald. Risikoen er st?rst for m?nd. For patienter med non-radiografisk spondylolartrit er risikoen utilstr?kkeligt belyst.Der henvises til DRS NBV for ”H?ndtering af risiko for osteoporose for patienter med artrit (RA, PsA og axSpA)” LINKColumnafrakturRisikoen for fraktur er st?rst ved avanceret sygdom med syndesmofytter, hvor der selv ved let traume, kan opst? tv?rg?ende, atypisk, potentiel meget ustabil frakturFraktur medf?rer stor risiko for neurologisk skade, der kan opst? akut eller gradvist.Fraktur kan forv?rres ved forkert h?ndtering, hvorfor columna b?r underst?ttes i den stilling, den havde f?r traumet. Udretning af cervikalcolumna ved anl?ggelse af stiv halskrave kan forv?rre frakturen og dermed risikoen for neurologisk skade.Atlantoaksial subluxation er set hos 2 % af patienter med AS.Ved vedvarende segment?r mekanisk smerte trods normalt RTG, skal der udredes for fraktur (se afsnit ”Ved frakturmistanke”).Kardiovaskul?r sygdom For patienter med AS er der en association mellem inflammation og for?get risiko for kardiovaskul?r sygdom.I EULAR rekommandationenPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BZ2NhPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [43] vedr. kardiovaskul?r sygdom ved bl.a. AS anbefales det, at alle patienter mindst hver 5. ?r og ved alle st?rre ?ndringer af medicinsk behandling risikovurderes iht. nationale retningslinjer.Specifikt for AS Aortainsufficiens eller hjerteblok (s?rligt AV-blok) kan ses hos op mod 10 % med stigende hyppighed ved l?ngere sygdomsvarighed.Sj?ldnere ses mitralinsufficiens og myokardiedysfunktion.Pr?valensen af hypertension og isk?misk hjertesygdom er ?get.Der anbefales ikke rutinem?ssig screening, men EKG og ekkokardiografi udf?res med lav t?rskel ved symptomer.Der henvises herudover til separat NBV vedr. vurdering og h?ndtering af dette. LINKNyresygdomDen vigtigste nyresygdom er amyloidose, der ses hos 5 % af patienter med AS, og som is?r i ?ldre studier var en ikke uv?sentlig d?ds?rsag. Amyloidose ses is?r efter lang tids sygdom med h?j sygdomsaktivitet med hypergammaglobulin?mi, forh?jet SR og perifer ledsygdom. NSAID nefropati er s?dvanligvis forbig?ende efter seponering.Betydningen af IgA-nefropati er uklar. Ved symptomer udf?res j?vnlig m?ling af p-kreatinin. Urinstix og m?ling af SR og gammaglobuliner foretages hos udvalgte patienter.Lungesygdom Restriktiv nedsat lungefunktion hos patienter med AS pga. costovertebral og costosternal ankylose ses ofte.Lungefibrose is?r apikalt ses sj?ldent, men kan ved symptomer p?vises med udvidet lungefunktionsunders?gelse og high-resolution computed tomogrphy (HRCT).Der anbefales ikke rutinem?ssigt unders?gelse af lungefunktion.Uddelegering af arbejdsopgaver til andre faggrupperDet er en foruds?tning for uddelegering af arbejdsopgaver til andre faggrupper, at der foreligger relevant uddannelse og at denne re-certificeres mindst hvert 3. ?r.Der fastl?gges fra DRS relevante uddannelsesprogrammer.Patientens perspektiv Denne NBV har v?ret i h?ring hos Gigtforeningen.Aspekter vedr?rende MR-skanningTekniske krav til MR-skanningBilledkvaliteten skal muligg?re en sikker diagnostik af knoglemarvs?dem og strukturelle forandringerTekniske krav til MR-skanning(Anbefaling til de billeddiagnostiske afdelinger)SI-ledColumna totalisFeltstyrkeOptimalt 1,5T; mindst 1TOptimalt 1,5T; mindst 1TField-of-view:Maksimalt 30 x 30Tilpasses til columna s?ledes at den fremstilles mest optimaltMatrix:STIR-sekvens >350T1-v?gtet sekvens >350STIR-sekvens >300T1-v?gtet sekvens >300Sekvenser: Obligat: Semi-coronal T1 v?gtetSemi-aksial STIR Semi-coronal STIRBrusksekvens eller semi-aksial T1-v?gtet, afh?ngig af lokale forholdObligat:Sagittal T1 v?gtet Sagittal STIR sekvensSupplerende:Supplerende aksiale og koronale sekvenser kan udf?res ved behov eller efter de lokale radiologiske afdelingers ?nskeSnittykkelse:Maks 4 mmMaks 4 mm (gerne 3- 4 mm)Snitafstand (gap)Maks 1 mm (gerne 0,4 mm)Maks 1 mm (gerne 0,3 – 0,4 mm)Aktuel forskningsbaseret viden vedr. MR-fund ved axSpA/AS og relevante differentialdiagnoser.Ved AS kan der efter nogen tid udvikles strukturelle forandringer i de omr?der af leddene, hvor der har v?ret inflammation. I omr?der, hvor der har v?ret knoglemarvs?dem kan der udvikles fedtinfiltration og erosive forandringer kan over tid ?ndre karakter til backfill og senere til ankylosePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYWtzeW1vd3ljaDwvQXV0aG9yPjxZZWFyPjIwMTQ8L1ll

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ADDIN EN.CITE.DATA [44]. Sm? fedtinfiltrationer er uspecifikke fund, som kan ses ved andre tilstande. Udtalte erosive forandringer, backfill og intra-artikul?r ankylose ses derimod sj?ldent ved andre tilstande end ASPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XZWJlcjwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [12] og er ofte ledsaget af subkondral sklerosering. Der kan ogs? v?re overvejende sklerosering (osteitis condensans ilii) med og uden ledsagende knoglemarvs?dem, som kan v?re beskedent og beliggende i relation til skleroseringen. Osteitis condenssans ilii ses ofte i den forreste del af os ilium og/eller os sacrumPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb2RkdWJueXk8L0F1dGhvcj48WWVhcj4yMDIwPC9ZZWFy

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ADDIN EN.CITE.DATA [12, 45]Ledfladerne i SI-leddene kan v?re uregelm?ssige, og recesser udg?r en del af den normale anatomiske variation, hvilket ikke m? tolkes som patologiske fund. Der findes dog normalvarianter, som kan give anledning til smerter, specielt accessoriske SI-led ADDIN EN.CITE <EndNote><Cite><Author>Umay</Author><Year>2020</Year><RecNum>4467</RecNum><DisplayText>[23]</DisplayText><record><rec-number>4467</rec-number><foreign-keys><key app="EN" db-id="d5dts9vrmpdezaevzwmx9xvfpef0erzzdwda" timestamp="1601297029">4467</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Umay, S. T.</author><author>Korkmaz, M.</author></authors></contributors><titles><title>Frequency of anatomical variation of the sacroiliac joint in asymptomatic young adults and its relationship with sacroiliac joint degeneration</title><secondary-title>Clinical anatomy</secondary-title></titles><periodical><full-title>Clinical Anatomy</full-title><abbr-1>Clin. Anat.</abbr-1><abbr-2>Clin Anat</abbr-2></periodical><pages>839-843</pages><volume>33</volume><section>839</section><dates><year>2020</year></dates><urls></urls></record></Cite></EndNote>[23]Ved MR af columna er fund af knoglemarvs?dem ved hvirvelhj?rnerne uden ledsagende squaring af hvirvelcorpara, og fund af fladeformet endeplade?dem ofte uspecifikke fund, idet det kan ses ved degenerative forandringer mens tilstedev?relse af ?dem ved flere costo-vertebral og costo-transversalled oftere er associeret med axSpA/AS. Inflammation i adskillige facetled er formentlig ogs? associeret med axSpA/AS. Forkortelser LINK Excel.Sheet.12 "C:\\Users\\Public\\Documents\\forkortelsesliste 3.3.17.xlsx" "Ark1!R1C1:R38C2" \a \f 5 \h \* MERGEFORMAT ForkortelseDefinitionAPAnterior-posteriorASAnkyloserende spondylitisASASThe Assessement of SpondyloArthritis international SocietyASDAS score?Ankylosing Spondylitis Disease Activity?ScoreAxSpANon-radiografisk inflammatorisk aksial spondylartritis BASDAIThe Bath Ankylosing Spondylitis Disease Activity Index (aktivitetsm?l, rapporteret af patienten)BASFIThe Bath Ankylosing Spondylitis Disease Function Index (funktionsm?l, rapporteret af patienten)BASMIThe Bath Ankylosing Spondylitis Disease Metrology Index (objektivt m?l for sygdommens sv?rhedsgrad ved l?geunders?gelse)bDMARDBiologisk l?gemiddelCRPC-Reaktivt ProteinCTComputer tomografiDANBIOLandsd?kkende klinisk kvalitetsdatabase for reumatologi, som er baseret p? indrapportering fra landets afdelinger og private klinikkerDISHDiffus Idiopatisk Skeletal HyperostoseDMARDDisease-modifying anti-rheumatic drugsDXA-skanningDual X-ray Absorptiometry scanningEULAREuropean League Against RheumatismGOPGenoptr?ningsplan til kommunal genoptr?ningHAQHealth Assessment Questionnaire for Rheumatoid ArthritisHLAHuman leukocyt antigenHLA-B27Human leukocyt antigen B-27 IBDinflammatorisk tarmsygdomICD10International Classification of Diseases 10th RevisionIL-17 h?mmerInterleukin?17-antistofMRMagnetisk resonans skanningNBVNational behandlings vejledningNSAIDNon-steroide antiinflammatoriske midlerNY kriterierNew York kriterierRTG R?ntgenunders?gelseSAPHOSAPHO syndrom med synovitis, acne, hyperostose, pustolosis palmoplantaris og ostitisSI-ledSakroiliakaledSpASpondylartritisSTIRShort tau inversion recovery (MR-sekvens hvor ?get vandindhold er hvidt og baggrunden sort pga. manglende fedtsignaler)TTesla (MR feltstyrke)T1-v?gtetMR-sekvens hvor fedtv?v fremtr?der lyst og vand m?rktTNFα-h?mmer Antistof rettet mod tumor nekrotiserende faktor?alfaReferencer ADDIN EN.REFLIST 1.van der Linden, S., H.A. 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