Multiple dimensions of spondyloarthritis: an enigma for rheumatologists

Karl Gaffney FRCP
Consultant Rheumatologist, Norfolk and Norwich University Hospital, Norwich, UK
Honorary Professor, Norwich Medical School, Chair, British Society for Spondyloarthritis, Chair, BSR axSpA Targeted Therapy Guidelines Committee, Member, National Early Inflammatory Arthritis National Audit Working Group

Even after so many advances in understanding of spondyloarthritis in the last decade, why are we still missing early spondyloarthritis at the primary care level?

Spondyloarthritis (SpA) is a challenging diagnosis. No single test can diagnosis or exclude the disease. Because of the diverse nature of the clinical phenotype, patients present to many different primary care providers (for example General Practitioners, Physiotherapists, Osteopaths, Chiropractors) who often fail to consider or recognize the unifying diagnosis. Awareness of SpA among the general population and health care practitioners remains poor. Common misconceptions include the fact that the disease is rare among women and that being HLA B27 positive is necessary to establish the diagnosis. Referral pathways and specialist SpA clinics are not well established so patients are often “lost” in primary care and consequently not referred to specialist rheumatology services. Possible strategies to shorten diagnostic delay are outlined in detail in the campaign.

How challenging is it to evaluate extra-musculoskeletal manifestations in spondyloarthritis?

One in three patients with SpA experience extra-musculoskeletal manifestations (the commonest being acute anterior uveitis (AAU), inflammatory bowel disease (IBD) and psoriasis (PSO)) during the course of their disease and 10% will have 2 or more. The prevalence of these manifestations increases with longer disease duration. Patients present to other secondary care specialists with these manifestations and can often become embedded in their respective services unless colleagues ask and examine for the presence of musculoskeletal features (chronic back pain, peripheral arthritis, enthesitis, dactylitis), therefore the opportunity to verify a diagnosis of SpA is often missed. Extra-musculoskeletal manifestations add to SpA complexity and disease burden in addition to impacting on the choice of appropriate advanced therapy.

How can we effectively collaborate with other medical specialties in the presence of extra-musculoskeletal manifestations in spondyloarthritis patients?

It is extremely important to educate our colleagues in other specialties in order to raise awareness of SpA and create referral pathways to channel patients through to rheumatology services. Think back pain plus AAU, IBD or PSO as a simple algorithm to enable this process. In addition, MSK radiology plays a pivotal role in diagnosis, therefore we must ensure that appropriate imaging protocols (especially MRI) are in place and radiologists are confident at recognizing the key features of SpA. Formal radiology/rheumatology MDTs are essential in order to achieve this objective.

Can we predict the emergence of extra-musculoskeletal manifestations in newly diagnosed axial or peripheral spondyloarthritis patients?

Predicting extra-musculoskeletal manifestations in SpA is difficult. The presence of HLA B27 is the best predictor of AAU, however vigilance is still the best tool in clinical practice.

You are the co-chair of the Guideline Working Group which is formulating upcoming British Society of Rheumatology Spondyloarthritis Guidelines. What are significant changes you foresee in upcoming guidance in comparison to 2017 guidelines?

It is almost 10 years since the last iteration of these guidelines. Pharmacological management has advanced considerably to incorporate new classes of biologic DMARDs (bDMARD, including biosimilars), targeted synthetic DMARDs (tsDMARD), and treatment strategies such as switching, treatment withdrawal, treat to target and drug tapering. The new guideline will provide a detailed appraisal of new evidence to best inform clinical practice.