Volume 5, Issue 9, September – 2020 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Pattern of Glucose Tolerance among Patients with

Peripheral Spondyloarthritis
A T M Tanveer Hasan1, Al-Mamun2
1
Assistant Professor of Rheumatology, Enam Medical College & Hospital, Savar, Dhaka; 2Rheumatology Registrar, Enam
Medical College & Hospital, Savar, Dhaka

Abstract I. INTRODUCTION

 Background & Objectives: The spondyloarthritis (SpA) family consists of

Peripheral spondyloarthritis is a variant of ankylosing spondylitis (AS), nonradiographic axial SpA
spondyloarthritis which usually has a chronic course. (nr-axSpA), peripheral SpA, psoriatic arthritis, SpA
There is an increased risk of cardiovascular diseases associated with Crohn’s disease and ulcerative colitis,
among patients with chronic inflammatory diseases in reactive arthritis and juvenile-onset SpA. The smaller
general. Coexisting diabetes mellitus can potentially add number of patients with predominantly peripheral
to the risk. The objective of this study was to determine manifestations of SpA (eg, arthritis, enthesitis, and
the frequency of glucose intolerance in patients with dactylitis, rather than back and spine pain) who do not meet
spondyloarthritis established classification criteria for AS, reactive arthritis,
psoriatic arthritis, or SpA related to inflammatory bowel
 Materials & Methods: disorders can be considered as having peripheral SpA1.
The study was conducted among 35 participants Only about 12 to 30 percent of SpA patients overall may
with peripheral spondyloarthritis who visited the exhibit predominantly peripheral SpA2. The point
Department of Rheumatology, Enam Medical College & prevalence of spondyloarthritis in Bangladesh is 1.2%3.
Hospital, Savar, Dhaka, Bangladesh from September,
2018 to January, 2020. The participants underwent The reasons for the classification of SpA into
either oral glucose tolerance test or estimation of categories are both historical and practical, but each
HbA1C. category does not necessarily represent a discrete entity -
the clinical, laboratory, and imaging findings can overlap.
 Results: The diagnosis and management approaches for patients
The mean age of participants was 43.96 years. The suspected of having any type of SpA are also similar in
majority (80%) of them were young to muddle-aged general4, 5.
(≤40 years). 22.9% of the participants were prediabetic.
Diabetes mellitus was found to be present in 37.1% of The major clinical features which differentiate
the participants. There was no significant difference spondyloarthritis (SpA) from other forms of arthritis are the
between the study population and the general distribution and type of musculoskeletal manifestations and
population in terms of frequency of prediabetes. But the certain extraarticular features. Patients with axial SpA
frequency of diabetes in the study population was characteristically have chronic low back pain. Patients with
higher than that in the general population. There was either axial or peripheral SpA can exhibit peripheral
no significant difference between males and females musculoskeletal features, which include dactylitis (sausage
with regard to the frequencies of prediabetes and DM. digits), enthesitis (heel pain and/or swelling), and
Moreover, there was no significant difference in the peripheral arthritis1.
frequencies of prediabetes and DM between young and
middle-aged to elderly population. In addition to having articular and extraarticular
features, ankylosing spondylitis increases the risk of
 Conclusion: ischaemic heart disease and stroke6, 7. Similarly psoriatic
Considering the greater burden of DM among arthritis increases the risk of preclinical atherosclerosis and
patients with peripheral spondyloarthritis across all age overt cardiovascular disease8, 9. DM is more common
groups, routine screening for DM may be indicated in among patients with psoriatic arthritis in comparison with
these individuals. the general population10. But no study has yet been
conducted to assess DM as a comorbidity in patients with
Keywords:- Peripheral Spondyloarthritis, Prediabetes, peripheral spondyloarthritis. Our study assessed the
Diabetes Mellitus. frequencies of both prediabetes and diabetes in patients
with axial spondyloarthritis visiting a tertiary care hospital
and compared the results with those in the general
Bangladeshi population.

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Volume 5, Issue 9, September – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
II. MATERIALS & METHODS sample size was due to a small proportion of individuals
with spondyloarthritis as a whole having purely peripheral
This study was conducted in the Department of involvement. Diabetes mellitus and prediabetes were
Rheumatology of Enam Medical College & Hospital, defined using criteria described in table 1 as per
Savar, Dhaka, Bangladesh from September 2018 to January recommendations of World Health Organization (WHO)
2020. 35 patients with peripheral spondyloarthritis were and American Diabetes Association (ADA)11, 12.
recruited and they underwent either oral glucose tolerance Individuals satisfying any of the criteria for prediabetes or
test (OGTT) or estimation of HbA1C. The relatively small DM were classified into the respective category.

Category Fasting Plasma Glucose Plasma Glucose 2 Hours HbA1C(%)

(mmol/L) after 75g of Glucose
(mmol/L)
Prediabetes 6.1-6.9 7.8-<11.1 5.7-6.4%
Diabetes Mellitus ≥7 ≥11.1 ≥6.5%
Table 1:- Citeria for Prediabetes & Diabetes Mellitus

III. RESULT

Ages of the participants ranged from 21 to 65 years. Mean age was 43.96 years. The participants were divided into three
groups according to their ages: young (18-40 years), middle aged (>40-60 years) and elderly (>60 years). 80% of the participants
were young to middle-aged. Figure 1 demonstrates the details of distribution of the participants across different age groups.

Fig 1:- Distribution of the Participants across Different Age Groups

57.1% of the participants were males and 42.9% were females. So the majority of the respondents were males.

Figure 2 below shows the pattern of glucose tolerance among participants.

Fig 2:- Pattern of Glucose Tolerance among Participants

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Volume 5, Issue 9, September – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
There was no significant difference (p≈0.98) between significantly higher (p≈0.0001) than the national prevalence
the frequency of prediabetes in our study (22.86%) and the of DM, which is about 10%.
prevalence of prediabetes, which was about 23% according
to a nationwide survey among 7541 Bangladeshi Table 2 shows gender wise distribution of participants
individuals13. On the other hand, the frequency of DM across different patterns of glucose tolerance
among patients with axial SpA in our study (37.1%) was (normal/prediabetes/diabetes mellitus).

Sex Pattern of Glucose Tolerance

Normal Prediabetes Diabetes Mellitus
Female 5 4 6
Male 9 4 7
Table 2:- Patterns of Glucose Tolerance among Males & Females

20% of the males were prediabetic and 35% of the respect to the frequency of prediabetes (p≈1.00) and DM
males were diabetic. Among the female participants, (p≈0.7).
26.67% had prediabetes and 40% had diabetes. There was
no significant difference between males and females with Table 3 shows the patterns of glucose tolerance across
different age groups.

Age Group Pattern of Glucose Tolerance Total

Normal Prediabetes DM
Young 9 3 4 16
(18-40 years) (56.25%) (18.75%) (25%) (100%)
Middle-Aged to Elderly (>40 5 5 9 19
years) (26.31%) (26.31%) (47.37%) (100%)
Table 3:- Glucose Tolerance Patterns across Different Age Groups

There was no significant difference between young- study conducted by Chen et al showed an increased risk of
aged and middle-aged to elderly groups in terms of diabetes among patients with ankylosing spondylitis17.
frequencies of prediabetes (p≈0.7) and diabetes (p≈0.29).
The majority of our participants were young to
IV. DISCUSSION middle-aged as expected18. There was no difference
between males and females with regard to the frequencies
Diabetes is a major public health problem worldwide, of prediabetes and DM as in the general population 13. In
especially in low-and-middle income countries, where more contrast with the greater prevalence of prediabetes and DM
than 80% of people reside14, 15. According to the estimate of in the middle-aged to elderly people from the general
International Diabetes Federation (IDF), the global population, our sudy showed similar frequencies of
prevalence of diabetes among adults in 2013 was 8.3%, prediabetes and DM across young and middle-aged to
which is 382 million people living with diabetes and elderly groups19, 20. This may be indicative of an increased
projected to increase beyond 592 million in less than 25 risk of developing prediabetes and diabetes in young
years14. The IDF Diabetes Atlas 5th edition projected that patients with peripheral spondyloarthritis in comparison
the prevalence of Bangladesh will rise to more than 50% by with the general young population.
next 15 years and that will place Bangladesh as the 8th
highest diabetic populous country in the world15. EULAR recommends vaccination of individuals with
autoimmune inflammatory rheumatic diseases (AIIRDs)
A nationwide survey (n=7541) among people in including spondyloarthritis considering the increased risk
Bangladesh conducted in 2011 revealed that the prevalence of infections in these individuals resulting from an
of prediabetes was about 23% and that of diabetes was immunosuppressive effect of the underlying AIIRD and the
about 10%13. The frequency of prediabetes among use of immunomodulatory drugs to treat the AIIRD21. The
peripheral SpA patients was similar to that in the general risk of infections is also increased in patients with DM22.
population, but the burden of diabetes was much higher. Moreover, both DM and chronic inflammatory diseases
Although there has been no such study so far on patients increase the risk of cardiovascular diseases23, 24. As our
with peripheral spondyloarthritis, similar findings were study demonstrated increased frequency of DM among
observed in patients with ankylosing spondylitis. For patients with axial SpA, we would like to recommend
instance, Liao et al. demonstrated higher incidence of DM routine screening of individulas in this disorder for DM as
among patients with ankylosing spondylitis16. Another an important measure to reduce the risk of infections and
cardiovascular diseases.

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Volume 5, Issue 9, September – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
V. CONCLUSION [9]. Jamnitski A, Symmons D, Peters MJ, Sattar N,
MciInnes I, Nurmohamed MT. Cardiovascular
There is a greater frequency of DM in patients with comorbidities in patients with psoriatic arthritis: a
peripheral spondyloarthritis compared with that in the systematic review. Annals of the rheumatic diseases.
general population. Routine screening for the presence of 2013 Feb 1;72(2):211-6.
diabetes mellitus should be a part of evaluation of these [10]. Eder L, Chandran V, Cook R, Gladman DD. The risk
individuals in the clinical settings. of developing diabetes mellitus in patients with
psoriatic arthritis: a cohort study. The Journal of
REFERENCES rheumatology. 2017 Mar 1;44(3):286-91.
[11]. World Health Organization. International Diabetes
[1]. Yu DT, van Tubergen A. Overview of the clinical Federation (2006) Definition and diagnosis of diabetes
manifestations and classification of spondyloarthritis. mellitus and intermediate hyperglycemia: report of a
UpToDate. Sieper J, Romain PL, ed. Maltham, MA: WHO/IDF consultation. IDF consultation. 2008.
UpToDate Inc. Available from: [12]. American Diabetes Association. 2. Classification and
https://www.uptodate.com/contents/overview-of-the- diagnosis of diabetes: standards of medical care in
clinical-manifestations-and-classification-of- diabetes—2019. Diabetes Care. 2019 Jan
spondyloarthritis?search=an%20overview%20of%20c 1;42(Supplement 1):S13-28.
linical%20manifestations%20and%20classification%2 [13]. Akter S, Rahman MM, Abe SK, Sultana P. Prevalence
0of%20spondyloarthritis&source=search_result&sele of diabetes and prediabetes and their risk factors
ctedTitle=1~150&usage_type=default&display_rank= among Bangladeshi adults: a nationwide survey.
1 (Updated 7 September 2018, cited 17 December Bulletin of the World Health Organization. 2014 Jan
2019) 10;92:204-13A.
[2]. Yu DT, van Tubergen A. Clinical manifestations and [14]. Aguiree F, Brown A, Cho N, Dahlquist G, Cho D,
diagnosis of peripheral spondyloarthritis in adults. Dodd D. Whiting (2013) IDF Diabetes Atlas. IDF
UpToDate. Sieper J, Romain PL, ed. Maltham, MA: Diabetes Atlas, 6th Edition, International Diabetes
UpToDate Inc. Available from: Federation, Basel.2013;74-90.
https://www.uptodate.com/contents/clinical- [15]. Islam SM, Purnat TD, Phuong NT, Mwingira U,
manifestations-and-diagnosis-of-peripheral- Schacht K, Fröschl G. Non‐Communicable Diseases
spondyloarthritis-in- (NCDs) in developing countries: a symposium report.
adults?search=peripheral%20spondyloarthritis&sourc Globalization and health. 2014 Dec;10(1):81.
e=search_result&selectedTitle=1~19&usage_type=def [16]. Liao K, Kuo Y, Lai S. Diabetes mellitus in ankylosing
ault&display_rank=1#H39 (Updated 7 March 2018, spondylitis. Annals of the Rheumatic Diseases
cited January 2020) Published Online First: 06 September 2019.
[3]. Ahmed S, Haq SA, Al-qadir AZ, Rahman MM, Paul [17]. Chen HH, Yeh SY, Chen HY, Lin CL, Sung FC, Kao
S. Survey on prevalence of rheumatic disorders in CH. Ankylosing spondylitis and other inflammatory
Bangladeshi adults. Ann Rheum Dis. 2017;76(2): spondyloarthritis increase the risk of developing type
1044-1045 2 diabetes in an Asian population. Rheumatology
[4]. Zeidler H, Amor B. The Assessment in international. 2014 Feb 1;34(2):265-70.
Spondyloarthritis International Society (ASAS) [18]. Brent HL. Ankylosing spondylitis and
classification criteria for peripheral spondyloarthritis undifferentiated spondyloarthropathy. Medscape.
and for spondyloarthritis in general: the Diamond HS, ed. New York, NY: Medscape LLC.
spondyloarthritis concept in progress. Ann Rheum Dis Available from:
2011; 70:1. https://emedicine.medscape.com/article/332945-
[5]. Zeidler H, Calin A, Amor B. A historical perspective overview#a1 (Updated 3 September 2019, cited
of the spondyloarthritis. Curr Opin Rheumatol 2011; January 2020)
23:327. [19]. Khardori R. Type 2 diabetes mellitus. Medscape.
[6]. Essers I, Stolwijk C, Boonen A, De Bruin ML, Griffing GT, ed. New York, NY: Medscape LLC.
Bazelier MT, de Vries F, van Tubergen A. Available from:
Ankylosing spondylitis and risk of ischaemic heart https://emedicine.medscape.com/article/117853-
disease: a population-based cohort study. Ann Rheum overview#a1 (Updated 4 December 2019, cited
Dis. 2016;75(1):203. January 2020)
[7]. Mathieu S, Soubrier M. Cardiovascular events in [20]. The Centre for Disease Control. National diabetes
ankylosing spondylitis: a 2018 meta-analysis. Annals statistics report 2017. 2017. Available from:
of the Rheumatic Diseases. 2019;78(6):e57. https://www.cdc.gov/diabetes/data/statistics-
[8]. Tam LS, Shang Q, Li EK, Tomlinson B, Chu TT, Li report/index.html (Cited January 2020)
M, Leung YY, Kwok LW, Wong KC, Li TK, Yu T.
Subclinical carotid atherosclerosis in patients with
psoriatic arthritis. Arthritis Care & Research: Official
Journal of the American College of Rheumatology.
2008;59(9):1322-31.

IJISRT20SEP549 www.ijisrt.com 776

Volume 5, Issue 9, September – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
[21]. Furer V, Rondaan C, Heijstek MW, Agmon-Levin N,
van Assen S, Bijl M, Breedveld FC, D'Amelio R,
Dougados M, Kapetanovic MC, van Laar JM. 2019
update of EULAR recommendations for vaccination
in adult patients with autoimmune inflammatory
rheumatic diseases. Annals of the rheumatic diseases.
2020 Jan 1;79(1):39-52.
[22]. Casqueiro J, Casqueiro J, Alves C. Infections in
patients with diabetes mellitus: A review of
pathogenesis. Indian journal of endocrinology and
metabolism. 2012 Mar;16(Suppl1):S27.
[23]. Gregg EW, Li Y, Wang J, Rios Burrows N, Ali MK,
Rolka D, Williams DE, Geiss L. Changes in diabetes-
related complications in the United States, 1990–
2010. New England Journal of Medicine. 2014 Apr
17;370(16):1514-23.
[24]. Hansen, P. R. Chronic inflammatory diseases and
atherosclerotic cardiovascular disease: Innocent
bystanders or partners in crime? Curr. Pharm. Des.
2018. 24(3): 281–290

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