This is a summary of NICE guidance as per BMJ article. The spondyloarthritides are a group of inflammatory conditions with some extra-articulate manifestations. They may be peripheral or axial and are often missed.
Note that this affects similar numbers of women and men, can occur in people who are HLA-B27 negative, and does not always show up on X-ray.
Assess for axial spondyloarthritis in patients with low back pain that started before the age of 45 years and has lasted for >3 months.
Criteria to look for, in those patients:
- Started < 35 years
- Waking with pain in second half of the night
- 1st degree relative with spondyloarthritis
- Current or past enthesitis (inflammation at tendon, ligament, or joint capsule insertions – shows up as pain, protracted stiffness, and prominent swellings of large insertions – inflammatory markers may be normal)
- Current or past arthritis
- Current or past psoriasis
- Improvement within 48 hours of taking NSAIDs
- Improvement with movement
- Buttock pain
Four or more of those criteria requires specialist referral; two or fewer is a ‘watch and wait’ with new assessment if new features develop. If a patient has exactly three, do an HLA-B27 test to tip the balance.
Psoriatic arthritis and peripheral spondyloarthritis
Refer if any of the criteria below:
Dactylitis (inflammation of a whole finger or toe)
Suspected new-onset inflammatory arthritis if not gout or pseudogout (urgent referral)
Enthesitis (see above) that has no apparent mechanical cause and also fits any of the following criteria:
- Multiple sites
- Associated back pain with no apparent cause
- Current or past uveitis or psoriasis
- Gastrointestinal or genitourinary infection
- 1st-degree relative with spondyloarthritis OR psoriasis
Note that, for both axial and peripheral spondyloarthritis, no single test or symptom can rule the diagnosis in or out; diagnosis is clinical and based on likelihood according to groups of symptoms/signs.
Management is 1st-line with NSAIDs and second-line with DMARDs; also specialist physiotherapy and also multidisciplinary input from specialties such as hydrotherapy and OT. Flare management may be with a mixture of exercise/stretches, and pain/fatigue management.