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Referral strategies for early diagnosis of axial spondyloarthritis

Nature Reviews Rheumatology volume 8, pages 262–268 (2012)Cite this article

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Abstract

The spectrum of HLA-B27-associated inflammatory spine diseases is referred to as axial spondyloarthritis (axSpA). AxSpA encompasses established ankylosing spondylitis (AS) but also nonradiographic axSpA, and can be classified according to the Assessment of SpondyloArthritis international Society classification criteria for axSpA. Specific and effective therapy for axSpA includes education, physiotherapy, NSAIDs and biologic agents, as appropriate. Patients with axSpA, however, are often diagnosed late in the course of the disease. As specific therapy is available, the effective identification of those individuals who are likely to have axSpA among patients with chronic back pain in primary care and their subsequent referral to a rheumatologist for establishing a correct diagnosis is worth pursuing. Candidate referral parameters that can easily be applied to patients with chronic back pain and age at onset ≤45 years (the target population) include inflammatory back pain (IBP) and positivity for HLA-B27. Following diagnostic work-up by a rheumatologist, these referral parameters, either alone or in combination, have led to the diagnosis of as many as 33–45% of patients within this target population with axSpA, 41–62% of whom had undiagnosed AS. Thus, educating primary care physicians on the value of IBP and HLA-B27 testing within this target population, and referral to a rheumatologist if one of these parameters is positive, is a promising approach to reduce the long delay in diagnosing patients with axSpA.

Key Points

  • The long delay of several years in diagnosing ankylosing spondylitis (AS) is unacceptable, as specific therapy is available

  • Inflammatory back pain (IBP) is the key clinical symptom of patients with axial spondyloarthritis (axSpA), including AS and nonradiographic axSpA, and is present in 70–80% of patients

  • HLA-B27 is the key laboratory marker of axSpA, present in 70–95% of patients

  • Referral programs have focused on patients with chronic back pain, age at onset ≤45 years and presence of at least one further spondyloarthritis parameter, including IBP and/or HLA-B27

  • In all referral programs, a diagnosis of axSpA was made in 33–45% of referred patients

  • Easy-to-apply referral parameters for primary care physicians will contribute to shortening the diagnostic delay in axSpA

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Figure 1: The concept of axSpA.
Figure 2: Proposed referral strategy for axial spondyloarthritis for primary care physicians.

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Author information

Authors and Affiliations

  1. Endokrinologikum Berlin, Jägerstrasse 61, Berlin, 10117, Germany

    Martin Rudwaleit

  2. Department of Medicine, Charité University Medicine, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12203, Germany

    Joachim Sieper

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Contributions

M. Rudwaleit and J. Sieper researched data for the article and substantially contributed to the discussion of content. M. Rudwaleit also wrote the article and edited the manuscript prior to submission.

Corresponding author

Correspondence to Martin Rudwaleit.

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Competing interests

M. Rudwaleit has been a member of a speakers bureau, or has served as a scientific advisor for Abbott, Chugai Pharmaceutical Co. (a subsidiary of Roche), MSD, Pfizer and UCB. In addition, he receives grants/research support from Abbott, MSD and Pfizer. J. Sieper has worked as a consultant for Abbott, Merck, Pfizer, Roche and UCB, has been a member of a speakers bureau for Abbott, Merck, Pfizer and UCB, and has received grant or research support from Abbott, Bristol-Myers Squibb, Merck, Pfizer and Roche.

Supplementary information

Supplementary Table 1

Comparison of clinical and laboratory SpA features relevant for axial SpA (DOC 95 kb)

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Rudwaleit, M., Sieper, J. Referral strategies for early diagnosis of axial spondyloarthritis. Nat Rev Rheumatol 8, 262–268 (2012). https://doi.org/10.1038/nrrheum.2012.39

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