Audit and Review of Ankylosing Spondylitis Management in Qatar

Introduction: AS is a chronic inflammatory condition with a worldwide distribution. AS diagnosis and treatment are well standardized with international guidelines for its management. However, the application for these guidelines varies from country to country and even from Centre to Centre in the same country. Hence, we are auditing our AS service. Method: Electronic medical records of AS patients attending the out-patient department for a full year were reviewed for various aspect of AS management. Results: We audit 205 AS attended the out-patient during one year. 26% of our cohort found to have nr-asSpA with M: F ratio was 1:1 as compared to 4:1 in patients with positive X-ray. Patients’ characteristics compared with other local and international studies. There were documentation issues. All our patients tried the NSAIDs as the first line and then moved to TNF-a biologics. 56% of our cohort were on biologics and 23% for those tested for latent tuberculosis, were positive and required treatment before starting the biologics. Only 7-10% had their objective assessment of ASDAS & BASDAI at various stage of their disease. Conclusions: In a routine clinic scenario, there are major documentation issues and discrepancies between what we should do and what is done.


Ankylosing spondylitis (AS) is a chronic inflammatory condition
and it is one of the main Spondyloarthropathy (SpA) group with a worldwide distribution [1]. The incidence is between 0.5-14 per 100,000 people per year [2,3]. Sacroiliac joints (SIJ) are the main joints involved in such patients and in some peripheral joints could be involved as well [4]. The main extra-articular manifestations of AS include anterior uveitis [5]. In the majority of the cases, the diagnosis could be delayed for a few years from the onset of its symptoms [6]. A few studies were conducted on the characteristics of AS in the Middle East [7][8][9][10].
AS diagnosis and treatment are well standardized with clear international guidelines for its management. However, the application for these guidelines varies from country to country and even from Centre to Centre in the same country. Hence, we are auditing our AS service as compared to one of the main international criteria.
We can't find any auditing for how good we are doing for our AS patients locally in the middle east. We always find some discrepancy between the evidence-based guidelines and what is practically done with regards to various disease management including the AS. Accordingly, our primary outcome from this project is to audit how we are doing regarding AS management compared with the evidenced-based practical guidelines. We also studied some of the characteristics of AS patients in Qatar as a secondary outcome.
31ST December 2017 were reviewed. The Diagnosis of Ankylosing spondylitis is based on positive symptomatic and radiological findings. We looked for the various aspect for AS including its characteristics, diagnosis, service, assessment and management as compared to the 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis as our benchmark for the comparison, which is one of the main evidence-based management recommendations criteria for axial spondyloarthritis [11]. of those on DMARDs suffered from peripheral joints involvements.

Criteria
We found there was a significant problem with lack of the objective assessment of disease severity and activity in the majority of our patients in various stages of their disease (Table 1). In total we founded 109 (53%) of our cohort were on biologics with Adalimumab (43%) was the most commonly used followed by Etanercept (26%) (Figure 1). Of those on biologics, 33 (30%) patients tried more than one biologic during their disease course.

Limitations
There is a major documentation issue for various aspects of AS management. It is a retrospective study.

Discussion
Our AS patient's characteristic as compared to our department previous study in 2015 [10] [13]. Uveitis figure was even much lower in Moroccans at 6.8% [14], but it was much higher (44.9%) in Iranians [15]. In systematic metanalysis uveitis reported to be present in 25.8% which was slightly higher in North America and Europe as compared to Asia and Latin America [16]. This difference in uveitis could be due to the differences in HLA-B27 prevalence in different areas.
HLA-B27 prevalence in our study of 70% was comparable to others in the region. In Saudi Arabia it was 68% [8], in Jordan 72% & 81% [7,17] and in Kuwait 82.6% [18]. However, HLA-B27 present in 90-95% of white western European AS as compared with 8% in their general population and the risk of AS developing is as high as 5% in HLA-B27 positive individuals and substantially higher 20% in HLA-B27 positive relatives of patients. However, most of HLA-B27 positive induvial remain healthy [19,20]. There is a significant delay of diagnosis of 11.4 years in those who were HLA-B27 negative as compared with 8.5 years in HLA-B27 positive patients [21]. It is difficult to compare the use of TNF-a blockers and other treatment due to the difference in when these studies have been done.
In our cohort we have found that 109 (53%) of our patients in our cohort were on biologics with Adalimumab was the most commonly used followed by Etanercept. In an audit in the UK, it has been found that 41% of their AS patients were on TNF-a blockers with Etanercept (51%) has slightly higher figures than Adalimumab (45%) and only 4% were on Infliximab [22].

Conclusion
Our study has the advantage of good sample size and addressing practical aspects of AS management. However, it has the limitations of being retrospective. It revealed the lack of documentation of many important aspects concerning AS management. It showed that disease activity and severity assessment has not carried out in the majority of our patients. It also highlighted the importance of doing the tuberculosis pre-biologic screening in the Middle East, as almost a quarter of our patients were found to have latent Tuberculosis and who needed to be treated before the start of the biologics. It is worth mentioning and taking into consideration that in Qatar the population is heterogeneous, and it mainly includes many other Arabs and Asians, which accounts for more than ¾ of the population. However, from the point of the audit of view, this should not affect our results.

Implications
Our study highlighted the discrepancies between what is evidenced based and what was the real-life scenarios in managing our patients with AS.