Recognizing Axial Spondyloarthritis: A Guide for Primary Care

Abstract

Axial spondyloarthritis (axSpA) is an important cause of chronic low back pain and affects approximately 1% of the US population. The back pain associated with axSpA has a characteristic pattern referred to as inflammatory back pain (IBP). Features of IBP include insidious onset before age 45 years, association with morning stiffness, improvement with exercise but not rest, alternating buttock pain, and good response to treatment with nonsteroidal anti-inflammatory drugs. In patients with IBP, it is essential to look for other features associated with spondyloarthritis (SpA), such as enthesitis, dactylitis, peripheral arthritis, extra-articular manifestations (eg, psoriasis, uveitis, or inflammatory bowel disease), human leukocyte antigen B27 positivity, and a family history of SpA. Axial SpA is underrecognized, and a delay of several years between symptom onset and diagnosis is common. However, with new and effective therapies available for the treatment of active axSpA, early recognition and diagnosis are of critical importance. For this narrative review, we conducted a literature search of English-language articles using PubMed. Individual searches were performed to identify potential articles of interest related to axSpA (search terms: ["axSpA" OR "axial SpA" OR "axial spondyloarthritis" OR "ankylosing spondylitis"]) in combination with terms related to IBP ("inflammatory back pain" OR "IBP" OR "chronic back pain" OR "CBP" OR "lower back pain" OR "LBP"), diagnosis (["diagn*" OR "classification"] AND ["criteria" OR "recommend*" OR "guidelines"]), and referral ("refer*"). No date range was formally selected, as we were interested in providing an overview of the evolution of these concepts in clinical practice. We supplemented the review with insights based on our clinical expertise. Patients with chronic back pain should be screened for IBP and other SpA features; suspicion for axSpA should trigger referral to a rheumatologist for further evaluation.

A Road Map of the Axial Spondyloarthritis Continuum

“…Screening of patients with inflammatory back pain or extra-articular manifestations of axSpA could shorten this delay. 13,56 TRIANGULATION OF LOCATION: DIAGNOSIS No diagnostic criteria currently exist for axSpA, and the current classification criteria can lead to confusion if misused in the diagnostic process. The 1984 modified New York criteria proposed that patients must have definitive sacroiliitis by classic radiography, defined as bilateral grade 2 or higher or unilateral grade 3 or higher sacroiliitis, to be classified as having r-axSpA.…”

“…For example, mechanical back pain is a differential diagnosis of particular concern because of some overlapping signs and symptoms, and patients with mechanical back pain would not benefit from axSpA treatment. 56 Instead, the standard for axSpA diagnosis remains clinician judgment when radiographic findings, physical examination findings, HLA-B27 status, C-reactive protein level, and presence of other SpA features are evaluated in totality. 56 Ongoing research on axSpA manifestations is being conducted to assist clinicians in making reasoned diagnostic decisions.…”

“…56 Instead, the standard for axSpA diagnosis remains clinician judgment when radiographic findings, physical examination findings, HLA-B27 status, C-reactive protein level, and presence of other SpA features are evaluated in totality. 56 Ongoing research on axSpA manifestations is being conducted to assist clinicians in making reasoned diagnostic decisions. A recent latent class analysis of patients from the SpondyloArthritis Caught Early (SPACE) and DEvenir des Spondylarthropathies Indifférenciées Récentes (DESIR) cohorts identified 3 recognizable clinical entities of axSpA.…”

Geographic Variations in Diagnosis and Treatment of Ankylosing Spondylitis in the United States: A Real-World Study

“…Ankylosing spondylitis (AS) is a chronic inflammatory immune-mediated condition primarily affecting the sacroiliac joints and spine, with a prevalence of 0.2-0.5% in the United States [1,2]. Patients with AS suffer mostly with inflammatory back pain, peripheral inflammatory arthritis, enthesitis, and dactylitis [2]. As a consequence of these symptoms, patients with AS have reduced capability to perform day-to-day tasks, ability to work, and overall health-related quality of life and increased need of care [3][4][5].…”

“…Ankylosing spondylitis (AS) is a chronic inflammatory immune-mediated condition primarily affecting the sacroiliac joints and spine, with a prevalence of 0.2–0.5% in the United States [ 1 , 2 ]. Patients with AS suffer mostly with inflammatory back pain, peripheral inflammatory arthritis, enthesitis, and dactylitis [ 2 ].…”