Drugs & Aging

, Volume 27, Issue 7, pp 523–531 | Cite as

Late-Onset Ankylosing Spondylitis and Spondylarthritis

An Update on Clinical Manifestations, Differential Diagnosis and Pharmacological Therapies
  • Éric ToussirotEmail author
Leading Article


Ankylosing spondylitis (AS) and spondylarthritis (SpA) are generally observed in young male patients but can be diagnosed in the elderly. These cases correspond to late-onset or late-diagnosed AS or SpA. The clinical presentation may be either typical axial disease with a more severe illness compared with young-onset disease, or peripheral oligoarthritis of the lower limbs with pitting oedema (late-onset peripheral spondylarthropathy). New criteria for axial SpA including MRI-determined modifications of the sacroiliac joints may help the clinician with diagnosis. The treatment options for late-onset/-diagnosed AS include the same drugs as those taken by patients with young-onset AS, i.e. NSAIDs, sulfasalazine and anti-tumour necrosis factor (TNF)-α agents. Anti-TNFα agents are very effective drugs in young-onset AS and SpA. However, the effectiveness and safety of this drug class has not been specifically evaluated in elderly AS/SpA patients, and caution is therefore required with use of these drugs in elderly patients with co-morbidities and/or polypharmacy. In particular, careful evaluation for the risk of infection and cardiovascular events is recommended before initiating anti-TNFα agents in this age category. However, safety data from elderly patients with rheumatoid arthritis seem reassuring. With the increasing life expectancy and the new diagnostic modalities for axial (and peripheral) SpA, it is likely that the number of patients (diagnosed) with late-onset AS/SpA will increase. Thus, the clinician must be familiar with the clinical characteristics and particularities of this group of inflammatory rheumatic diseases.


Infliximab Ankylose Spondylitis Etanercept Sacroiliac Joint Bath Ankylose Spondylitis Disease Activity Index 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to assist in the preparation of this article. The author has no conflicts of interest that are directly relevant to the content of this article.


  1. 1.
    Calin A. Terminology, introduction, diagnostic criteria and overview. In: Calin A, Taurog JD, editors. The spondylarthritides. Oxford UK: Oxford University Press, 1998: 1–15Google Scholar
  2. 2.
    Toussirot E, Wendling D. Current guidelines for the drug treatment of ankylosing spondylitis. Drugs 1998; 56: 225–40PubMedCrossRefGoogle Scholar
  3. 3.
    Clegg DO, Reda DJ, Abdellatif M. Comparison of sulfasalazine and placebo for the treatment of axial and peripheral articular manifestations of seronegative spondylarthropathies. A Department of Veterans Affairs Cooperative Study. Arthritis Rheum 1999; 42: 2325–9PubMedCrossRefGoogle Scholar
  4. 4.
    Gonzalez-Lopez L, Garcia-Gonzalez A, Vasquez-Del-Mercado M, et al. Efficacy of methotrexate in ankylosing spondylitis: a randomized, double blind, placebo controlled trial. J Rheumatol 2004; 31: 1568–74PubMedGoogle Scholar
  5. 5.
    Wendling D, Toussirot E. Anti-TNFα therapy in ankylosing spondylitis. Exp Opin Pharmacother 2004; 5: 1497–507CrossRefGoogle Scholar
  6. 6.
    Toussirot E, Wendling D. Late onset ankylosing spondylitis and related spondylarthropathies: clinical and radiological characteristics and pharmacological treatment options. Drugs Aging 2005; 22: 451–69PubMedCrossRefGoogle Scholar
  7. 7.
    Carbone LD, Cooper C, Michet CJ, et al. Ankylosing spondylitis in Rochester, Minnesota 1935–1989. Is the epidemiology changing? Arthritis Rheum 1992; 35: 1476–82PubMedCrossRefGoogle Scholar
  8. 8.
    Rudwaleit M, Van der Heijde DM, Landewé R, et al. The development of Assessment of SpondyloArthritis International Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 2009; 69: 777–83CrossRefGoogle Scholar
  9. 9.
    Rudwaleit M, Jurik AG, Hermann KG, et al. Defining active sacroiliitis on magnetic resonance imaging for classification of axial spondylarthritis: a consensual approach by ASAS/OMERACT MRI group. Ann Rheum Dis 2009; 68: 1520–7PubMedCrossRefGoogle Scholar
  10. 10.
    Weber U, Hodler J, Kubik RA et al. Sensitivity and specificity of spinal inflammatory lesions assessed by whole body magnetic resonance imaging in patients with ankylosing spondylitis or recent onset inflammatory back pain. Arthritis Rheum 2009; 61: 900–8PubMedCrossRefGoogle Scholar
  11. 11.
    Dubost JJ, Sauvezie B. Late onset peripheral spondylarthropathy. J Rheumatol 1989; 16: 1214–7PubMedGoogle Scholar
  12. 12.
    Caplanne D, Tubach F, Le Parc JM. Late onset spondylarthropathy: clinical and biological comparison with early onset patients. Ann Rheum Dis 1997; 56: 176–9PubMedCrossRefGoogle Scholar
  13. 13.
    Olivieri I, Padula A, Pierro A, et al. Late onset seronegative spondylarthropathy. J Rheumatol 1995; 22: 899–903PubMedGoogle Scholar
  14. 14.
    Punzi L, Pianon M, Rossini P, et al. Clinical and laboratory manifestations of elderly onset psoriatic arthritis: a comparison with younger onset disease. Ann Rheum Dis 1999; 58: 226–9PubMedCrossRefGoogle Scholar
  15. 15.
    Gonzalez-Juanatey C, Vazquez-Rodriguez TR, Miranda-Filloy JA, et al. The high prevalence of subclinical atherosclerosis in patients with ankylosing spondylitis without clinically evident cardiovascular disease. Medicine 2009; 88: 358–65PubMedCrossRefGoogle Scholar
  16. 16.
    Peters MJ, Visman I, Nielsen MM, et al. Ankylosing spondylitis; a risk factor for myocardial infarction? Ann Rheum Dis 2010; 69: 579–81PubMedCrossRefGoogle Scholar
  17. 17.
    Gilworth G, Emery P, Barkham N, et al. Reducing work disability in ankylosing spondylitis: development of a work instability scale for AS [abstract]. BMC Musculoskelet Disord 2009; 10: 68PubMedCrossRefGoogle Scholar
  18. 18.
    Montacer Kchir M, Mehdi Ghannouchi M, Hamdi W, et al. Impact of the ankylosing spondylitis on the professional activity. Joint Bone Spine 2009; 76: 378–82PubMedCrossRefGoogle Scholar
  19. 19.
    Singh JA, Strand V. Spondylarthritis is associated with poor function and physical health related quality of life. J Rheumatol 2009; 36: 1012–20PubMedCrossRefGoogle Scholar
  20. 20.
    Kujath K, Hermann KG, Mathiske-Schmidt K, et al. Severe disease activity and complications of immunosuppressive therapy: a challenge for acute hospital based rehabilitation in rheumatology. J Rheumatol 2009; 36: 1618–25PubMedCrossRefGoogle Scholar
  21. 21.
    Healey EL, Haywood KL, Jordan KP, et al. Ankylosing spondylitis and its impact on sexual relationships. Rheumatology 2009; 48: 1378–81PubMedCrossRefGoogle Scholar
  22. 22.
    Martindale J, Smith J, Sutton CJ, et al. Disease and psychological status in ankylosing spondylitis. Rheumatology 2006; 45: 1288–93PubMedCrossRefGoogle Scholar
  23. 23.
    McCarty DJ, O’Duffy JD, Pearson L, et al. Remitting synovitis seronegative symmetric synovitis with pitting edema (RS3PE) syndrome. JAMA 1985; 254: 2763–7PubMedCrossRefGoogle Scholar
  24. 24.
    Olivieri I, Pipitone N, D’Angelo S, et al. Late onset rheumatoid arthritis and late onset spondylarthritis. Clin Exp Rheumatol 2009; 27Suppl. 55: S139–45PubMedGoogle Scholar
  25. 25.
    Olivieri I, D’Angelo S, Palazzi C, et al. Diffuse idiopathic skeletal hyperostosis: differentiation from ankylosing spondylitis. Curr Rheumatol Rep 2009; 11: 321–8PubMedCrossRefGoogle Scholar
  26. 26.
    Lukas C, Landewé R, Sieper J, et al., Assessment of SpondyloArthritis international Society. Development of an ASAS-endorsed disease activity score (ASDAS) in patients with ankylosing spondylitis. Ann Rheum Dis 2009; 68: 18–24PubMedCrossRefGoogle Scholar
  27. 27.
    Anderson JJ, Baron G, Van Der Heijde D, et al. Ankylosing spondylitis assessment group preliminary definition of short-term improvement in ankylosing spondylitis. Arthritis Rheum 2001; 44: 1876–86PubMedCrossRefGoogle Scholar
  28. 28.
    Inman RD, Davis JC, Van der Heijde D, et al. Efficacy and safety of golimumab in patients with ankylosing spondylitis: results of a randomized, double-blind, placebo-controlled, phase III trial. Arthritis Rheum 2008; 58: 3402–12PubMedCrossRefGoogle Scholar
  29. 29.
    Melmed GY, Targan SR, Yasothan U, et al. Certolizumab pegol. Nat Rev Drug Discov 2008 Aug; 7(8): 641–2PubMedCrossRefGoogle Scholar
  30. 30.
    Braun J, Brandt J, Listing J, et al. Treatment of active ankylosing spondylitis with infliximab: a randomized controlled multicentre trial. Lancet 2002; 359: 1187–93PubMedCrossRefGoogle Scholar
  31. 31.
    Davis JC, Van Der Heijde D, Braun J, et al. Recombinant human tumor necrosis factor receptor (etanercept) for treating ankylosing spondylitis: a randomized, controlled trial. Arthritis Rheum 2003; 48: 3230–6PubMedCrossRefGoogle Scholar
  32. 32.
    Van der Heijde D, Kivitz A, Schiff M, et al. Efficacy and safety of adalimumab in patients with ankylosing spondylitis: results of a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2006; 54: 2136–46PubMedCrossRefGoogle Scholar
  33. 33.
    Van der Heijde D, Landewé R, Baraliakos X, et al. Radiographic findings following two years of infliximab therapy in patients with ankylosing spondylitis. Arthritis Rheum 2008; 58: 3063–70PubMedCrossRefGoogle Scholar
  34. 34.
    Braun J, Baraliakos X, Listing J, et al. Decreased incidence of anterior uveitis in patients with ankylosing spondylitis treated with the anti-tumor necrosis factor agents infliximab and etanercept. Arthritis Rheum 2005; 52: 2447–51PubMedCrossRefGoogle Scholar
  35. 35.
    Mease PJ, Goffe BS, Metz J, et al. Etanercept in the treatment of psoriatic arthritis and psoriasis: a randomised trial. Lancet 2000; 356: 385–90PubMedCrossRefGoogle Scholar
  36. 36.
    Antoni C, Kavanaugh A, Kirkham B, et al. Sustained benefits of infliximab therapy for dermatologic and articular manifestations of psoriatic arthritis: results from the Infliximab Multinational Psoriatic Arthritis Controlled Trial (IMPACT). Arthritis Rheum 2005; 52: 1227–36PubMedCrossRefGoogle Scholar
  37. 37.
    Gladman DD, Mease PJ, Ritchlin CT, et al. Adalimumab for long-term treatment of psoriatic arthritis: forty-eight week data from the Adalimumab Effectiveness in Psoriatic Arthritis Trial. Arthritis Rheum 2007; 56: 476–88PubMedCrossRefGoogle Scholar
  38. 38.
    Braun J, Davis J, Dougados M, et al. First update of the international consensus statement for the use of anti TNFα agents in patients with ankylosing spondylitis. Ann Rheum Dis 2006; 65: 316–20PubMedCrossRefGoogle Scholar
  39. 39.
    Ritchlin CT, Kavanaugh A, Gladman DD, et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis 2009; 68: 1387–94PubMedCrossRefGoogle Scholar
  40. 40.
    Radovits BJ, Kievit W, Laan RFJM. Tumour necrosis factor α antagonists in the management of rheumatoid arthritis in the elderly: a review of their efficacy and safety. Drugs Aging 2009; 26: 647–64PubMedCrossRefGoogle Scholar
  41. 41.
    Fleischmann R, Baumgartner SW, Weisman MH, et al. Long term safety of etanercept in elderly subjects with rheumatic diseases. Ann Rheum Dis 2006; 65: 379–84PubMedCrossRefGoogle Scholar
  42. 42.
    Fleischmann R, Iqbal I. Risk: benefit profile of etanercept in elderly patients with rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis. Drugs Aging 2007; 24: 239–54PubMedCrossRefGoogle Scholar
  43. 43.
    Schneeweiss S, Setoguchi S, Weinblatt L, et al. Anti-tumor necrosis factor α therapy and the risk of serious bacterial infections in elderly patients with rheumatoid arthritis. Arthritis Rheum 2007; 56: 1754–64PubMedCrossRefGoogle Scholar
  44. 44.
    Genevay S, Finchk A, Ciurea A, et al. Tolerance and effectiveness of anti-tumor necrosis factor α therapies in elderly patients with rheumatoid arthritis: a population based cohort study. Arthritis Rheum 2007; 57: 679–85PubMedCrossRefGoogle Scholar
  45. 45.
    Radovits BJ, Kievit W, Fransen J, et al. Influence of age on the outcome of antitumour necrosis factor alpha therapy in rheumatoid arthritis. Ann Rheum Dis 2009; 68: 1470–3PubMedCrossRefGoogle Scholar
  46. 46.
    Bathon JM, Fleischmann R, Van der Heijde DM, et al. Safety and efficacy of etanercept treatment in elderly subjects with rheumatoid arthritis. J Rheumatol 2006; 33: 234–43PubMedGoogle Scholar
  47. 47.
    Fillipini M, Bazzani C, Favalli EG, et al. Efficacy and safety of anti-tumour necrosis factor in elderly patients with rheumatoid arthritis: an observational study. Clin Rev Allerg Immunol. Epub 2009 Jun 23Google Scholar
  48. 48.
    Ornetti P, Chevillotte H, Zerrak A, et al. Anti-tumour necrosis factor α therapy for rheumatoid arthritis and other inflammatory arthropathies: update on safety in older patients. Drugs Aging 2006; 23: 855–60PubMedCrossRefGoogle Scholar
  49. 49.
    Tran S, Hooker RS, Cipher DJ, et al. Patterns of biologic agent use in older males with inflammatory diseases: an institution-focused, observational post marketing study. Drugs Aging 2009; 26: 607–15PubMedCrossRefGoogle Scholar
  50. 50.
    Migliore A, Bizzi E, Lagana B, et al. The safety of anti TNFα agents in the elderly. Int J Immunopathol Pharmacol 2009; 22: 415–26PubMedGoogle Scholar
  51. 51.
    Chevillotte-Maillard H, Ornetti P, Mistrih R, et al. Survival and safety of treatment with infliximab in the elderly population. Rheumatology 2005; 44: 695–6PubMedCrossRefGoogle Scholar
  52. 52.
    Setoguchi S, Schneeweiss S, Avorn J, et al. Tumor necrosis factor α antagonist use and heart failure in elderly patients with rheumatoid arthritis. Am J Heart 2008; 156: 336–41CrossRefGoogle Scholar
  53. 53.
    Diaz-Borjon A. Guidelines for the use of conventional and newer disease modifying antirheumatic drugs in elderly patients with rheumatoid arthritis. Drugs Aging 2009; 26: 273–93PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  1. 1.Department of RheumatologyUniversity Hospital Jean MinjozBesançon cedexFrance
  2. 2.Équipe d’Accueil 4266, Agents Pathogènes et InflammationUniversity of Franche-ComtéBesançonFrance
  3. 3.CIC - Biotherapy 506University Hospital St-JacquesBesançonFrance

Personalised recommendations