Druckschmerzhafte Körperstellen – Enthesitis?

Zusammenfassung

Die Enthesitis ist eine häufige Manifestation bei Spondyloarthritiden (SpA) und Psoriasis- Arthritis (PsA) und tritt bei bis zu 40 % der Patienten mit SpA auf. Wegen ihrer pathognomonischen Bedeutung ist Enthesitis in verschiedenen Klassifikationskriterien für SpA und PsA als ein Eingangs- oder Nebenkriterium aufgenommen worden. Häufigste Lokalisation ist die Ferse, aber Enthesitiden können ubiquitär an Sehnenansätzen in den Knochen auftreten. Bei der Diagnose der Enthesitis sind zahlreiche Differenzialdiagnosen zu beachten, insbesondere sollten mechanisch-degenerative Ursachen unterschieden und eine Fibromyalgie ausgeschlossen werden. Als bildgebende Verfahren sind der Power Doppler Ultraschall (PDUS) und die Magnetresonanztomografie (MRT) besonders diagnostisch hilfreich. Die therapeutischen Optionen bei Enthesitis sind begrenzt. Es werden die Gabe von nichtsteroidalen Antirheumatika und lokale Steroidinjektionen empfohlen. Während in kleineren Studien für Disease Modifying Antirheumatic Drugs keine Wirksamkeit gezeigt werden konnte, haben sich TNF-alpha-Blocker, Anti-IL-17-, Anti-IL-12/23- sowie Anti-IL-23-Antikörper in randomisierten kontrollierten Studien sowohl bei SpA als auch/oder bei PsA als effektiv erwiesen. Sie sind jedoch derzeit nicht für die Therapie einer alleinig vorliegenden Enthesitis zugelassen.

Summary

Enthesitis is a frequent manifestation in spondyloarthritides (SpA) and psoriatic arthritis (PsA) and can be found in up to 40 % of patients with SpA. Because of the pathognomonic relevance the classification criteria for SpA and PsA are using enthesitis as entrance- or secondary criterion. Enthesitis is most frequently localized at the heel but it can occur at any insertion of an enthesis into the bone. When diagnosing enthesitis differential diagnoses should be considered, especially mechanic-degenerative causes and fibromyalgia should be excluded. The imaging techniques power Doppler ultrasound (PDUS) and Magnetic Resonance Imaging (MRI) are most helpful in making the diagnosis. The therapeutic options for enthesitis are limited. Nonsteroidal antirheumatic drugs and local injections of corticosteroids are recommended to use. In small clinical trials no efficacy of disease-modifying antirheumatic drugs could be demonstrated. In contrast, TNF alpha blockers Anti-IL-17- and Anti-IL-12/23 as well as Anti-IL-23-antibodies were shown to be highly effective in randomized controlled trials in SpA and/or PsA, but for enthesitis only, currently they are not approved.

Schlüsselwörter

Spondyloarthritis - Enthesitis - Enthesiopathie - Psoriasis-Arthritis - ankylosierende Spondylitis

Keywords

Spondyloarthritis - enthesitis - enthesopathy - psoriatic arthritis - ankylosing spondylitis

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