What is the management plan for an adolescent with HLA (Human Leukocyte Antigen) B27?

Management of Adolescents with HLA-B27

For adolescents with HLA-B27 positivity, regular ophthalmologic screening is essential due to their risk for both chronic anterior uveitis (CAU) and acute anterior uveitis (AAU), with screening recommended every 6-12 months depending on risk factors. 1

Screening and Monitoring Recommendations

• Adolescents with HLA-B27 positivity should be considered at moderate risk for uveitis, particularly those with enthesitis-related arthritis, and require ophthalmologic screening every 6-12 months 1
• Education regarding warning signs of acute anterior uveitis (eye pain, redness, photophobia) is strongly recommended to decrease delay in treatment and reduce complications 1
• If diagnosed with uveitis, monitoring should occur no less frequently than every 3 months while on stable therapy 1
• More frequent monitoring (within 1 month after changes in topical glucocorticoids or within 2 months after changes in systemic therapy) is strongly recommended for those with diagnosed uveitis 1

Clinical Evaluation

• Complete rheumatologic history and examination of all peripheral joints for tenderness, swelling, and range of motion; examination of the spine is necessary 1
• For chronic back pain (>3 months) with onset before age 45, assess for inflammatory characteristics including:
  • Morning stiffness >30 minutes
  • Nocturnal/early morning pain
  • Improvement with exercise 2, 3
• Consider referral to rheumatology if the patient has chronic back pain with onset before age 45 AND at least four of the following: back pain occurring before age 35, night pain, buttock pain, improvement with exercise or NSAIDs, first-degree relative with spondyloarthritis, or current/previous arthritis, enthesitis, or psoriasis 2

Diagnostic Approach

• HLA-B27 testing should be used as a screening parameter rather than a definitive diagnostic test 2
• Approximately 30-40% of patients with chronic back pain and positive HLA-B27 ultimately receive an ankylosing spondylitis diagnosis 2
• Do not rule out spondyloarthritis based solely on a negative HLA-B27 test, normal C-reactive protein, or normal erythrocyte sedimentation rate 2
• Consider imaging (radiography or MRI) to evaluate for sacroiliitis in patients with suspected axial spondyloarthritis 2, 3

Treatment Recommendations

For Arthritis/Spondyloarthritis:

• First-line treatment: NSAIDs at full dose, regardless of HLA-B27 status 3
• Short-term use of NSAIDs is safe if inflammatory bowel disease is in remission, but long-term use or use in active IBD carries risk of worsening symptoms 1
• For persistent peripheral arthritis, consider sulfasalazine 3
• For patients with active disease despite NSAIDs:
  • TNF inhibitors (adalimumab, infliximab) are recommended as first-line biologics 3
  • Secukinumab or ixekizumab are recommended for primary non-response to TNF inhibitors 3

For Acute Anterior Uveitis:

• For AAU in patients with well-controlled spondyloarthritis, topical glucocorticoids are recommended as first-line treatment without immediate changes to systemic therapy 1
• For frequent recurrent episodes of AAU, consider changing from a non-monoclonal antibody TNF inhibitor to a monoclonal antibody TNF inhibitor 1

Special Considerations

• HLA-B27 positive boys with older age at disease onset have higher risk of more extensive joint involvement 4
• HLA-B27 positivity is associated with inflammatory back pain in both sexes, but with enthesitis primarily in boys 4
• HLA-B27 positive patients may show resistance to therapy with disease-modifying drugs and corticosteroids compared to HLA-B27 negative patients 5
• The presence of HLA-B27 does not affect disease onset age but may predict more severe disease course and treatment resistance 5

Monitoring Disease Progression

• Patients with inflammatory arthritis should be monitored with serial rheumatologic examinations, including inflammatory markers, every 4–6 weeks after treatment is instituted 1
• Systematic radiographic monitoring with serial spine radiographs is not recommended 3
• MRI of the spine or pelvis may help evaluate disease activity when clinical assessment is uncertain 3