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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

  • Back pain > 3months with onset <45yrs of age
  • Does not improve on resting
  • Insidious onset
  • 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)
  • Buttock pain alternating with back pain
  • Dactylitis of fingers or toes

Examination

  • Reduced range of spine movements

Peripheral joint examination for synovitis

Refer to the rheumatology if the patient has five of the following six features of inflammatory back pain OR fourof 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.

How to refer:

  • Please refer using SCIgw > WGH> 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

What happens next?

When the results are through you will get a further letter indicating whether the patient will be offered a face to face follow up at rheumatology (if there is evidence of AxSpA) or if they are being discharged to primary care (where there is no evidence of AxSpA)

Your referral will be reviewed by a triage consultant and checked for completeness. If the criteria are met, you and the patient will get a letter to indicate that a MRI scan has been requested

Investigations

  • Raised CRP or ESR (may be normal)
  • Routine bloods otherwise unremarkable
  • HLA B27 usually positive

Initial management

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