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.

Axial spondyloarthritis

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:

  • Persistent
  • Multiple sites
  • Associated back pain with no apparent cause
  • Current or past uveitis or psoriasis
  • IBD
  • 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.


About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in BMJ, Credits 2017, Rheumatology. Bookmark the permalink.

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