Wednesday, 1 November 2017

NICE Guidelines on Spondyloarthritis - a guide for GPs and referrers

The NICE Guidelines on Spondyloarthritis – A guide for GPs and referrers

Dr. Antoni Chan, PhD FRCP
Consultant Rheumatologist, Royal Berkshire Hospital and Spire Dunedin Hospital, Reading

A summary of the National Institute for Health and Care Excellence. Spondyloarthritis in over 16s: diagnosis and management (NICE guideline NG65) 2017.


The spondyloarthropathies (SpAs) encompasses a group of inflammatory conditions with shared features. These include extra-articular manifestations such as iritis, colitis and psoriasis. The SpAs can be divided into:

Axial (spinal) spondyloarthritis
  • Non-radiographic axial spondyloarthritis (positive MRI, negative X-ray for sacroilitis)
  • Radiographic axial spondyloarthritis (also called Ankylosing Spondylitis)
Peripheral spondyloarthritis
  • Psoriatic Arthritis (arthritis related to skin psoriasis)
  • Reactive Arthritis (arthritis occurring after gastrointestinal or genitourinary infection)
  • Enteropathic Arthritis (arthritis related to Ulcerative or Crohn’s colitis)
The clinical manifestations of spondyloarthritis include
  • Enthesitis – inflammation at sites of tendon insertion in the bone eg. Achilles tendon
  • Dactylitis – inflammation of the whole digit giving ‘sausage’ like appearance
  • Acute anterior uveitis
When to suspect SpA and refer to rheumatologist?
  • Presence of inflammatory low back pain before the age of 45 years and has lasted for more than 3 months
  • Low back pain that improves with movement and worse with rest
  • Alternating buttock pain
  • Waking during the second half of the night due to symptoms
  • Improvement within 48 hours of taking NSAIDs
  • Current or previous arthritis (swelling, tenderness of joints)
  • Current or previous enthesitis
  • Current or previous dactylitis
  • Current or previous psoriasis
  • First degree relative with spondyloarthritis
If 4 or more of these clinical features are present please refer.
If 3 clinical features are present, check the HLA- B27 blood test and refer.
If 2 or fewer clinical features are present, advise repeat assessment if new signs or symptoms related to SpAs develop

What further tests can be done by a rheumatologist after referral?
  • X-ray of sacroiliac joint
  • MRI of whole spine and sacroiliac joints
  • Inflammatory markers (ESR, CRP)
  • HLA-B27
What treatments are available?
  • Physiotherapy
  • Injections
  • Clinical Psychology
  • Occupational Therapy
  • NSAIDs
  • Disease modifying drugs (DMARDs)`
  • Anti-TNF (biologics)
  • Secukinumab (biologic)
GPs and referrers can refer to their local rheumatology departments for suspected AS or SpA.

There is a dedicated Ankylosing Spondylitis clinic at the Royal Berkshire Hospital, Reading (NHS) and Spire Dunedin Hospital, Reading (private). Dr. Chan runs both clinics with physiotherapists.

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