Spondyloarthritis in over 16s: diagnosis and management

National Institute for Health and Care Excellence


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  • Spondyloarthritis is a group of inflammatory conditions that have a range of manifestations. Spondyloarthritis may be predominantly:
    • axial:
      • radiographic axial spondyloarthritis (ankylosing spondylitis)
      • non-radiographic axial spondyloarthritis or
    • peripheral:
      • psoriatic arthritis
      • reactive arthritis
      • enteropathic spondyloarthritis
  • People with predominantly axial spondyloarthritis may have additional peripheral symptoms, and vice versa
  • Axial presentations of spondyloarthritis are often misdiagnosed as mechanical low back pain, leading to delays in access to effective treatments. Peripheral presentations are often seen as unrelated joint or tendon problems, and can be misdiagnosed because problems can move around between joints

Recognition and referral in non-specialist care settings

  • Do not rule out the possibility that a person has spondyloarthritis solely on the presence or absence of any individual sign, symptom or test result

Suspecting spondyloarthritis

  • Recognise that spondyloarthritis can have diverse symptoms and be difficult to identify, which can lead to delayed or missed diagnoses. Signs and symptoms may be musculoskeletal (for example, inflammatory back pain, enthesitis and dactylitis) or extra-articular (for example, uveitis and psoriasis [including psoriatic nail symptoms]). Risk factors include recent genitourinary infection and a family history of spondyloarthritis or psoriasis
  • Be aware that axial and peripheral spondyloarthritis may be missed, even if the onset is associated with established comorbidities (for example, uveitis, psoriasis, inflammatory bowel disease [Crohn's disease or ulcerative colitis], or a gastrointestinal or genitourinary infection)
  • Be aware that axial spondyloarthritis:
    • affects a similar number of women as men
    • can occur in people who are human leukocyte antigen B27 (HLA-B27) negative
    • may be present despite no evidence of sacroiliitis on a plain film X-ray

Referral for suspected axial spondyloarthritis

  • If a person has low back pain that started before the age of 45 years and has lasted for longer than 3 months, refer the person to a rheumatologist for a spondyloarthritis assessment 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 the likelihood that back pain is due to spondyloarthritis compared with low back pain that started between 35 and 44 years)
    • waking during the second half of the night because of symptoms
    • buttock pain
    • improvement with movement
    • improvement within 48 hours of taking non-steroidal anti-inflammatory drugs (NSAIDs)
    • a first-degree relative with spondyloarthritis
    • current or past arthritis
    • current or past enthesitis
    • current or past psoriasis
  • If exactly three 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
  • If the person does not meet the criteria in recommendation but clinical suspicion of axial spondyloarthritis remains, advise the person to seek repeat assessment if new signs, symptoms or risk factors listed in recommendation develop. This may be especially appropriate if the person has current or past inflammatory bowel disease (Crohn's disease or ulcerative colitis), psoriasis or uveitis (see referral for suspected acute anterior uveitis, below)

Referral for suspected psoriatic arthritis and other peripheral spondyloarthritides

  • For guidance on identifying spondyloarthritis in people with an existing diagnosis of psoriasis, see assessment and referral for psoriatic arthritis in the NICE guideline on psoriasis
  • Urgently refer people with suspected new-onset inflammatory arthritis to a rheumatologist for a spondyloarthritis assessment, unless rheumatoid arthritis, gout or acute calcium pyrophosphate (CPP) arthritis ('pseudogout') is suspected.
  • If rheumatoid arthritis is suspected, see referral for specialist treatment in the NICE guideline on rheumatoid arthritis in adults
  • Refer people with dactylitis to a rheumatologist for a spondyloarthritis assessment
  • Refer people with enthesitis without apparent mechanical cause to a rheumatologist for a spondyloarthritis assessment if:
    • it is persistent or
    • it is in multiple sites or
    • any of the following are also present:
      • back pain without apparent mechanical cause
      • current or past uveitis 
      • current or past psoriasis
      • gastrointestinal or genitourinary infection
      • inflammatory bowel disease (Crohn's disease or ulcerative colitis)
      • a first-degree relative with spondyloarthritis or psoriasis

Recognising psoriasis

  • If a person with suspected spondyloarthritis has signs or symptoms of undiagnosed psoriasis, follow the recommendations in the NICE guideline on psoriasis

Referral for suspected acute anterior uveitis

  • Refer people for an immediate (same-day) ophthalmological assessment if they have symptoms of acute anterior uveitis (for example, eye pain, eye redness, sensitivity to light or blurred vision)

Case-finding in people with acute anterior uveitis

  • Ophthalmologists should ask people with acute anterior uveitis whether they have: 
    • consulted their GP about joint pains or
    • experienced low back pain that started before the age of 45 years and has lasted for longer than 3 months
  • If the person meets either of the criteria above establish whether they have psoriasis or skin complaints that appear psoriatic on physical examination
  • If they do, refer the person to a rheumatologist for a spondyloarthritis assessment
  • If they do not, perform an HLA-B27 test. If the test is positive, refer the person to a rheumatologist for a spondyloarthritis assessment

Information and support

Information about spondyloarthritis

  • Provide people with spondyloarthritis, and their family members or carers (as appropriate), with information that is:
    • available on an ongoing basis 
    • relevant to the stage of the person's condition 
    • tailored to the person's needs
  • For more guidance on providing information to people and discussing their preferences with them, see the NICE guideline on patient experience in adult NHS services
  • Provide explanations and information about spondyloarthritis, for example:
    • what spondyloarthritis is
    • diagnosis and prognosis
    • treatment options (pharmacological and non-pharmacological), including possible side-effects
    • likely symptoms and how they can be managed
    • flare episodes and extra-articular symptoms
    • self-help options
    • opportunities for people with spondyloarthritis to be involved in research
    • which healthcare professionals will be involved with the person's care and how to get in touch with them
    • information about employment rights and ability to work
    • local support groups, online forums and national charities, and how to get in touch with them

Information about disease flares

  • Advise people with spondyloarthritis about the possibility of experiencing flare episodes and extra-articular symptoms.
  • Consider developing a flare management plan that is tailored to the person's individual needs, preferences and circumstances.
  • When discussing any flare management plan, provide information on:
    • access to care during flares (including details of a named person to contact [for
    • example, a specialist rheumatology nurse])
    • self-care (for example, exercises, stretching and joint protection)
    • pain and fatigue management
    • potential changes to medicines
    • managing the impact on daily life and ability to work

Pharmacological management of spondyloarthritis

Axial spondyloarthritis

NSAIDs

  • Offer NSAIDs at the lowest effective dose to people with pain associated with axial spondyloarthritis, and think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
  • If an NSAID taken at the maximum tolerated dose for 2–4 weeks does not provide adequate pain relief, consider switching to another NSAID

Please refer to the full guideline for information on:

  • Biological DMARDs:
    • adalimumab, certolizumab pegol, etanercept, golimumab and infliximab for the treatment of ankylosing spondylitis and non-radiographic axial spondyloarthritis
    • secukinumab for the treatment of ankylosing spondylitis

Psoriatic arthritis and other peripheral spondyloarthritides

Non-biological therapies

  • Consider local corticosteroid injections as monotherapy for non-progressive monoarthritis
  • Offer standard disease-modifying anti-rheumatic drugs (DMARDs) to people with:
    • peripheral polyarthritis
    • oligoarthritis
    • persistent or progressive monoarthritis associated with peripheral spondyloarthritis
  • When deciding which standard DMARD to offer, take into account:
    • the person's needs, preferences and circumstances (such as pregnancy planning and alcohol consumption)
    • comorbidities such as uveitis, psoriasis and inflammatory bowel disease
    • disease characteristics potential side-effects
  • If a standard DMARD taken at the maximum tolerated dose for at least 3 months does not provide adequate relief from symptoms, consider switching to or adding another standard DMARD
  • Consider NSAIDs as an adjunct to standard DMARDs or biological DMARDs to manage symptoms. Use oral NSAIDs at the lowest effective dose for the shortest possible period of time, and think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
  • If NSAIDs do not provide adequate relief from symptoms, consider steroid injections (local or intramuscular) or short-term oral steroid therapy as an adjunct to standard DMARDs or biological DMARDs to manage symptoms.
  • If extra-articular disease is adequately controlled by an existing standard DMARD but peripheral spondyloarthritis is not, consider adding another standard DMARD

Please refer to the full guideline for information on:

  • Targeted synthetic DMARDs—apremilast for the treatment of psoriatic arthritis
  • Biological DMARDs:
    • etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
    • golimumab for the treatment of psoriatic arthritis
    • ustekinumab for the treatment of psoriatic arthritis

Reactive arthritis

Antibiotics

  • After treating the initial infection, do not offer long-term (4 weeks or longer) treatment with antibiotics solely to manage reactive arthritis caused by a gastrointestinal or genitourinary infection

Non-pharmacological management of spondyloarthritis

  • Refer people with axial spondyloarthritis to a specialist physiotherapist to start an individualised, structured exercise programme, which should include:
    • stretching, strengthening and postural exercises
    • deep breathing
    • spinal extension
    • range of motion exercises for the lumbar, thoracic and cervical sections of the spine
    • aerobic exercise
  • Consider hydrotherapy as an adjunctive therapy to manage pain and maintain or improve function for people with axial spondyloarthritis
  • Consider a referral to a specialist therapist (such as a physiotherapist, occupational therapist, hand therapist, orthotist or podiatrist) for people with spondyloarthritis who have difficulties with any of their everyday activities. The specialist therapist should:
    • assess people's needs
    • provide advice about physical aids
    • arrange periodic reviews to assess people's changing needs

Surgery for spondyloarthritis

  • Do not refer people with axial spondyloarthritis to a complex spinal surgery service to be assessed for spinal deformity correction unless the spinal deformity is:
    • significantly affecting their quality of life and
    • severe or progressing despite optimal non-surgical management (including physiotherapy)
  • If a person with axial spondyloarthritis presents with a suspected spinal fracture, refer them to a specialist to confirm the spinal fracture and carry out a stability assessment. After the stability assessment, the specialist should refer people with a potentially unstable spinal fracture to a spinal surgeon

Managing flares

  • Manage flares in either specialist care or primary care depending on the person's needs
  • When managing flares in primary care, seek advice from specialist care as needed, particularly for people who:
    • have recurrent or persistent flares
    • are taking biological DMARDs
    • have comorbidities that may affect treatment or management of flares
  • Be aware that uveitis can occur during flare episodes. See Referral for suspected acute anterior uveitis (above) for guidance on immediate (same-day) ophthalmological assessment for people with acute anterior uveitis

Long-term complications

  • For guidance on monitoring long-term pharmacological treatments, see the NICE guideline on medicines optimisation
  • Take into account the adverse effects associated with NSAIDs, standard DMARDs and biological DMARDs when monitoring spondyloarthritis in primary care
  • Advise people that there may be a greater risk of skin cancer in people treated with TNF-alpha inhibitors
  • Discuss risk factors for cardiovascular comorbidities with all people with spondyloarthritis
  • Consider regular osteoporosis assessments (every 2 years) for people with axial spondyloarthritis. Be aware that bone mineral density measures may be elevated on spinal dual-energy X-ray absorptiometry (DEXA) due to the presence of syndesmophytes and ligamentous calcification, whereas hip measurements may be more reliable
  • Advise people with axial spondyloarthritis that they may be prone to fractures, and should consult a healthcare professional following falls or physical trauma, particularly in the event of increased musculoskeletal pain

Organisation of care

Co-ordinating care across settings

  • Commissioners should ensure that local arrangements are in place to coordinate care for people across primary and secondary (specialist) care. These should cover:
    • prescribing NSAIDs and standard DMARDs
    • monitoring NSAIDs, standard DMARDs and biological DMARDs
    • managing flares
    • ensuring prompt access to specialist rheumatology care when needed
    • ensuring prompt access to other specialist services to manage comorbidities and
    • extra-articular symptoms
  • Ensure that people with spondyloarthritis have access to specialist care in primary or secondary care settings throughout the disease course to ensure optimal long-term spondyloarthritis management (see above section for arrangements for managing flares)
  • Ensure that there is effective communication and coordination between all healthcare professionals involved in the person's care, particularly if the person has comorbidities or extra-articular symptoms
  • Ensure that there is communication and coordination between rheumatology and other relevant specialities (such as dermatology, gastroenterology and ophthalmology). This is particularly important for people who: are already receiving standard DMARDs or biological DMARDs for another condition need to start taking standard DMARDs or biological DMARDs for another condition
  • For guidance on managing the transition of young people with juvenile idiopathic arthritis to adult services, see the NICE guideline on transition from children's to adults' services for young people using health or social care services

References

full guideline available from...
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/NG65

National Institute for Health and Care Excellence. Spondyloarthritis in over 16s: diagnosis and management. February 2017.


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