Suspecting spondyloarthritis

1.1.2.

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.

1.1.3.

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).

1.1.4.

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

1.1.5.

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 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.

1.1.6.

If the person does not meet the criteria in recommendation 1.1.5 but clinical suspicion of axial spondyloarthritis remains, advise the person to seek repeat assessment if new signs, symptoms or risk factors listed in recommendation 1.1.5 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 recommendation 1.1.12 for guidance on referral for immediate [same-day] ophthalmological assessment for people with acute anterior uveitis).

Referral for suspected psoriatic arthritis and other peripheral spondyloarthritides

1.1.7.

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.

1.1.8.

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.

1.1.9.

Refer people with dactylitis to a rheumatologist for a spondyloarthritis assessment.

1.1.10.

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 (see recommendation 1.1.12 for guidance on immediate [same-day] ophthalmological assessment for people with acute anterior 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

1.1.11.

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

1.1.12.

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

1.1.13.

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.

1.1.14.

If the person meets either of the criteria in recommendation 1.1.13, 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.

Diagnostic criteria for suspected spondyloarthritis

1.2.1.

In specialist care settings, consider using validated spondyloarthritis criteria to guide clinical judgement when diagnosing spondyloarthritis. Examples include:

• general spondyloarthritis criteria:

  –

  Amor

  –

  European Spondyloarthropathy Study Group (ESSG)

• axial spondyloarthritis criteria:

  –

  Assessment of Spondyloarthritis International Society (ASAS; axial)

  –

  Berlin

  –

  Rome

  –

  modified New York

• peripheral spondyloarthritis criteria:

  –

  ASAS (peripheral)

  –

  Classification of Psoriatic Arthritis (CASPAR)

• French Society of Rheumatology (reactive arthritis).

1.2.2.

Do not rule out a diagnosis of spondyloarthritis solely on the basis of a negative HLA-B27 result.

1.2.3.

Do not rule out a diagnosis of spondyloarthritis if a person’s C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are normal.

Imaging for suspected axial spondyloarthritis

Imaging for suspected psoriatic arthritis and other peripheral spondyloarthritides

1.2.11.

Offer plain film X-ray of symptomatic hands and feet for people with suspected peripheral spondyloarthritis in these areas.

1.2.12.

If a diagnosis cannot be made from the plain film X-ray, consider ultrasound of:

• the hands and feet to assess for joint involvement
• suspected enthesitis sites.

1.2.13.

Consider plain film X-rays, ultrasound and/or MRI of other peripheral and axial symptomatic sites.

1.2.14.

Interpret a positive HLA-B27 result as increasing the likelihood of peripheral spondyloarthritis.

1.2.15.

If a diagnosis of peripheral spondyloarthritis is confirmed, offer plain film X-ray of the sacroiliac joints to assess for axial involvement, even if the person does not have any symptoms.

Antibody testing for suspected reactive arthritis

1.2.16.

Do not routinely test for infective antibody status to diagnose reactive arthritis in people with a history of gastrointestinal infection.

Information about spondyloarthritis

1.3.1.

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.

1.3.2.

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

1.3.3.

Advise people with spondyloarthritis about the possibility of experiencing flare episodes and extra-articular symptoms.

1.3.4.

Consider developing a flare management plan that is tailored to the person’s individual needs, preferences and circumstances.

1.3.5.

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.

Axial spondyloarthritis

Psoriatic arthritis and other peripheral spondyloarthritides

Reactive arthritis

Coordinating care across settings

1.9.1.

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.

1.9.2.

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 section 1.7 for arrangements for managing flares).

1.9.3.

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.

1.9.4.

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.

1.9.5.

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.

Why this is important

The Dutch CaFaSpA study (van Hoeven et al. 2014, 2015) should be repeated in a UK population. This would involve examining GP databases to identify a cohort of people who have a diagnosis of non-specific back pain who first consulted their GP for back symptoms under the age of 45. These people would be invited for a full rheumatological assessment (including identifying signs and symptoms relevant to axial spondyloarthritis, X-ray, MRI and HLA-B27 test). All participants would be given a reference-standard diagnosis of axial spondyloarthritis or not (ideally using expert clinician opinion, or if this is not possible, using the ASAS [Assessment of Spondyloarthritis International Society] classification criteria). The cohort would be split into a development and validation set, to derive and validate optimal rules for case-finding from the available data, with each candidate strategy judged according to expected cost per quality-adjusted life year (QALY) gained (the NICE economic model developed for this guideline could easily be used to estimate these).

As a result of the large number of permutations of possible referral strategies, it is impractical to run separate validation studies for all referral criteria that are developed. Therefore, a single large, representative cohort study would, provided it measured the predictor variables for all reasonable referral strategies, provide the ability to develop and validate any number of possible referral strategies. The study would need to be large enough that sufficient data are available to derive new referral rules and to validate those rules in a separate, independent subset of the data. A UK-specific dataset would provide more relevant data to do this than is currently available from the Dutch CaFaSpA study. For example, that study found an HLA-B27 prevalence of 20% in people with axial spondyloarthritis and 2% in people without; much lower than the estimates found elsewhere (75% and 20% respectively). This lowers the validity of extrapolating any results found to the UK, and reinforces the need for UK-specific data to address this question.

Why this is important

Spondyloarthritides are a group of systemic inflammatory conditions, and as such it is thought that people with these conditions may have an elevated risk of CVD, particularly if their disease is not adequately controlled. This may have direct vascular effects as well as precluding maintenance of a good level of cardiovascular fitness.

There is also clinical uncertainty around the long-term use of non-steroidal anti-inflammatory drugs (NSAIDs): whether the long-term CVD risks associated with this class of drugs are observed in this population, or whether the suppression of inflammation with these drugs mitigates some of the CVD risks associated with these conditions. In addition, risks of osteoporosis and fracture are known to be higher in people with axial spondyloarthritis than the general population, and the prevalence of axial manifestations in people diagnosed with peripheral disease implies the risks may also be high in peripheral spondyloarthritis.

The longer-term complication rates in the spondyloarthritides need to be established, as well as whether standard biological disease-modifying anti-rheumatic drug (DMARD) therapies and biological DMARDs influence these outcomes. Research that evaluates incidence of osteoporosis, CVD and metabolic syndrome in people with either axial or peripheral spondyloarthritis compared with the general population would therefore be of value. This research should take into account disease stage, personal activity levels and medicine use, and look to address how frequently it is appropriate to monitor people with spondyloarthritis for long-term complications.

Why this is important

One of the major reasons for the delays in diagnosing spondyloarthritis is a lack of awareness of the condition by healthcare professionals. This can take many forms, such as a lack of awareness of different spondyloarthritis subtypes, lack of knowledge about associated clinical features (for example, the differences between inflammatory and mechanical back pain) or characteristics of the patient populations (for example, that spondyloarthritis affects similar numbers of men and women, or that a substantial proportion of people with spondyloarthritis are HLA-B27 negative). Educational interventions to improve the level of awareness may therefore lead to reductions in diagnosis delays, but there is a lack of evidence as to the efficacy of these interventions. Randomised controlled trials of structured educational interventions are therefore needed to assess both whether they reduce the length of time it takes for people to be correctly diagnosed, and whether they represent a cost-effective use of NHS resources.

Why this is important

The committee noted that, although there are a number of randomised controlled trials comparing standard DMARDs with placebo for managing peripheral spondyloarthritis, there is a lack of evidence comparing individual standard DMARDs to other standard DMARDs. This lack of evidence makes it difficult to optimise initial therapy, either by specifying specific drugs within the class or optimising dose, administration and monitoring protocols. There is therefore the need for randomised controlled trials looking at alternative drug, dosing and administration route alternatives for the administration of standard DMARDs for managing peripheral spondyloarthritis. These trials should ensure NSAIDs and steroids are available to participants as needed, and should include (as outcome measures) both health-related quality of life (measured using the EQ-5D) and health service resource use, to enable the results to be used to assess the cost effectiveness of the interventions.

Why this is important

Although there have been trials conducted of biological therapies for psoriatic arthritis, which have led to positive recommendations in NICE technology appraisals, no such good-quality evidence exists in enteropathic arthritis, reactive arthritis or undifferentiated spondyloarthritis. The substantial side effects possible with biological therapies, and their significant cost, means it is difficult to justify offering them to these groups without good evidence of efficacy. There is therefore the need for randomised controlled trials, with a sufficient sample size to identify possible benefits, in these 3 populations. If trials were to recruit participants from multiple spondyloarthritis subpopulations, results should be clearly stratified by diagnosis to enable any differences in benefits or harms between the groups to be identified. These trials should include (as outcome measures) both health-related quality of life (measured using the EQ-5D) and health service resource use, to enable the results to be used to assess the cost effectiveness of the interventions.