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. 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.