Axial Spondyloarthritis Referral Guideline

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Axial SpA (axSpA) is a chronic inflammatory condition predominantly involving the spine and sacroiliac joints (SIJ), with or without extra-spinal manifestations including peripheral arthritis, enthesitis, iritis, psoriasis and inflammatory bowel disease (IBD).

History

A key feature of axial SpA is low back pain in patients below 45 years of age, waking at night, improving with movement and responding to non-steroidal anti-inflammatory drugs usually within 48 hours.

Risk factors include psoriasis, IBD, recent genitourinary infection and a family history of spondyloarthritis or psoriasis.

Examination

  • Reduced range of spinal movements, hip and chest expansion.
  • Check for: peripheral arthritis, enthesitis, dactylitis, psoriasis (including psoriatic nail symptoms), and uveitis.

Helpful Investigations

  • ESR and CRP – usually elevated.
  • HLA-B27 – may be normal.

Primary Care Management

  • Treat symptoms with full dose NSAID and/or analgesics pending clinic review.
  • Early involvement of the allied health care team (physiotherapy, OT, orthotics, podiatry, etc.) should be considered.

Who to Refer

Refer patients with low back pain that started before the age of 45 years and has lasted for longer than 3 months, and if 4 or more of the following additional criteria are also present:

  • low back pain that started before the age of 35 years (this further increases likelihood of axial spondyloarthritis),
  • waking during second half of the night, because of symptoms,
  • buttock pain,
  • improvement with movement,
  • improvement with taking non-steroidal anti-inflammatory drugs (often within 48 hours),
  • a first-degree relative with spondyloarthritis,
  • current or past arthritis,
  • current or past enthesitis,
  • current or past psoriasis.

If exactly 3 of the additional criteria are present, perform an HLA‑B27 test. If the test is positive, refer the person to a rheumatologist for a spondyloarthritis assessment.

When screening criteria are not met but clinical suspicion remains, advice the person to seek repeat assessment if new signs, symptoms or risk factors develop. This may be particularly appropriate if the person has or had psoriasis, inflammatory bowel disease or uveitis.

Who Not to Refer

If there is no evidence of inflammatory back pain in the history (as described above). Consider NHSL Lumbar/Spinal Pathway for other cases.

Last reviewed: 01 November 2020

Next review: 01 November 2022

Author(s): Dr Anna Ciechomska

Co-Author(s): Rheumatology team: Dr Robin Munro, Dr Karen Donaldson, Dr Elizabeth Murphy, Dr James Dale, Dr Sanjiv Nandwani, Dr Georgiana Young, Dr May Chee, Mr Nico Groenendijk; GP representatives: Dr Tyra Smith, Dr Mark Russell, Dr Linda Findlay, Dr Paul Deehan, Dr Lucy Munro; Medical directorate: Dr Mehrdad Malekian

Approved By: Dr Karen Donaldson

Reviewer Name(s): Dr Anna Ciechomska