Axial spondyloarthritis

Axial Spondyloarthritis is a chronic inflammatory condition targeting the sacroiliac joints and the spine. It typically starts in the late teens and early 20’s but can present up to 45 years of age. It has been estimated that AxSpA accounts for <5% of chronic back pain.

History

Insidious onset
Back pain or alternating buttock pain > 3months with onset <45yrs of age
Worse with rest
Pain at night improving on rising
Early morning stiffness improving with exercise
Good response to NSAID

Associated features

History of iritis or uveitis
History of psoriasis
History of inflammatory bowel disease
Positive family history of AxSpA
Peripheral large joint synovitis
Heel pain (enthesitis)
Dactylitis of fingers or toes

Examination

Reduced range of spine movements
Flattening of lumbar lordosis, exaggerated thoraic kyphosis
Sacroiliac joint tenderness is not a reliable all useful sign for differentiating inflammatory from non inflammatory back pain
Peripheral joint examination for synovitis
Skin/scalp/nail examination for psoraisis

Who to refer, who not to refer, how to refer

Please see primary care management section.

Refer to the rheumatology if the patient has five of the following six features of inflammatory back pain OR four of the six and at least one additional feature of AxSpA:

Features of inflammatory back pain

Duration >3 months, onset aged <45 years
Made worse with rest
Insidious onset
Pain wakening in the second half of the night
Early morning stiffness improving with exercise
Good response to NSAID

Additional features of AxSpA

A history of uveitis / iritis
Heel pain suggestive of enthesitis
Clinical evidence of peripheral arthritis
Clinical evidence of dactylitis
A history of psoriasis
A history of inflammatory bowel disease
A raised CRP or ESR
A family history of AxSpA, inflammatory bowel disease, reactive arthritis, psoriasis or uveitis.

How to refer:

Please refer using SCIgw > BGH> Rheumatology> Axial Spondyloarthritis
Please summarise in your referral which of the above clinical features of AxSpA the patient had presented with.
Take blood for U&E, LFT, FBC and CRP
Arrange for plain films of lumbar spine and sacroiliac joints

What happens next?

Your referral will be triaged by a consultant. If appropriate the patient will be offered a clinic appointment. If the probability of AxSpA is considered to be low you will receive a letter of advice

Primary care management

Investigations

Raised CRP or ESR (may be normal)
Routine bloods otherwise unremarkable
Do not test for HLA-B27 positivity – 8% of the UK population are HLA-B27 positive, most of these do not have AxSPA

Initial management

Commence trial of treatment with NSAID; either Naproxen 500mg bd or Etoricoxib 60mg daily