Axial spondyloarthritis

• General Rheumatology consultations (consultants, specialty doctors, specialist nurses, ANP, senior Pharmacist)
• AHP (Rheumatology Physiotherapy, Podiatry, Occupational Therapy)
• US scan of the joints (for internal referrals only)
• Intraarticular steroid injections (for internal referrals only or performed by Rheumatology Physiotherapist)
• Training for self-delivered subcutaneous injections (internal use only)
• Medical Day Unit (internal service for delivery of intravenous medication, subcutaneous medication, Short Synacthen test)
• Rheumatology on-call (quick access to the service, prompt reply to enquiries via email)
• Rheumatology page 1439 – covered by resident doctor.
• Rheumatology helpline  - 01292513316 – Service run by Rheumatology specialist nurses.

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

Suspected axial spondyloarthritis (inflammatory back pain)

Low back pain that has lasted for >3 months and if four or more of the following additional criteria are also present:

• Low back pain that started before the age of 35 years
• Waking during the second half of the night because of symptoms
• Alternating buttock pain
• Improvement with movement
• Improvement within 48 hours of taking non-steroidal anti-inflammatory drugs Does not improve on resting
• Insidious onset
• Pain at night improving on rising
• Early morning stiffness improving with exercise
• A first-degree relative with spondyloarthritis
• Current or past arthritis
• Current or past history of enthesitis.

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)
• Buttock pain alternating with back pain
• Dactylitis of fingers or toes.

Examination

• Reduced range of spine movements
• Peripheral joint examination for synovitis.

Refer to Rheumatology by using SCI OP Gateway, 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
• Does not improve on resting
• Insidious onset
• Pain at night improves on rising
• Early morning stiffness improving with exercise
• Good response to NSAID.

Additional features of AxSpA

• A history of uveitis / iritis
• Heel pain suggestive if 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
• Buttock pain alternating with back pain
• A family history of AxSpA, inflammatory bowel disease, reactive arthritis, psoriasis or uveitis.

Do not send new referrals only for updates or to ask for urgent review do to flares for patients already known to rheumatology, being on the list waiting for reviews, as we cancel such referrals to avoid duplication.

Please do not hesitate to keep in touch with us regarding your patients with any updates, symptom changes or flare ups using the Rheumatology Clinical email inbox: clinicalr@aapct.scot.nhs.uk 

Please summarise in your referral which of the above clinical features of Suspected AxSpA, the patient had presented with.

Take blood for U&E, LFT, FBC, ESR and CRP

• Refer to lumbar spine X ray and/or for targeted joint x ray
• You may start on oral NSAIDs
• Do not commence steroids
• The patient may be referred to physiotherapy local/hospital to start rehabilitation programme.
• Do not check Rheumatoid arthritis factor nor ANA for patients with back pain as they do not help with diagnosis and might create confusion and distress to patients
• Do not refer to Rheumatology patients with non-inflammatory back pain, you must refer them for Physiotherapy / MSK back pain pathway
• Rheumatoid arthritis never affects lumbar spine or sacroiliac joints.

1. British Society for Rheumatology Adult Rheumatology Referral Guidance. September 2021. Accessed at: https://www.rheumatology.org.uk/Portals/0/Documents/Policy/Adult-rheumatology-referral-guidance.pdf?ver=2022-08-04-104812-413
2. NHS Lanarkshire Rheumatology referral guidelines. March 2022. Accessed at: https://rightdecisions.scot.nhs.uk/media/2014/ebooklet-rheumatology-referrals-2022.pdf
3. NHS Lothian. RefHep. Accessed at:RefHelp – Instant Acces s to Referral Guidelines for Lothian