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. www.nice.org.uk/guidance/ng65.
Background
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.
