1. Axial Spondyloarthropathy
Dr Rosh Sathananthan FRCP
Consultant Rheumatologist

2. Case 1:
Age 40 year old man Long standing history of back pain since a teenager Neck, lower back and buttock area Early morning stiffness 2 hours Symptoms severe until excluding meat and dairy from diet Medication: Ibuprofen 200mg bd

3. Last episode 12 months ago
Past medical history:
Psoriasis
Recurrent uveitis
Last episode 12 months ago
Suggested by ophthalmologists he may have Axial SpA
HLA B27 positive
Blood tests: ESR 29 CRP 14

4. Examination
Restricted ROM cervical, thoracic and lumbar spine Chest expansion 4.5 cm Schober’s index 5 cm Hip movements normal

5. MRI Scan: Thoracic spine: Lumbar spine: Sacroiliac joints:
Fusion of the posterior elements T1-6
Inflammation costovertebral and uncovertebral joints
Lumbar spine:
No significant inflammatory changes
Sacroiliac joints:
Almost complete fusion but no bony oedema

6. Case 1
BASDAI 6.7 Spinal VAS 6 Not keen on biologics at present or increased dose of NSAID Jointly agreed tracking of BASDAI and further review Recommended NASS group at CUH – prefers self management

7. Case 2
Age 38 year old man Nine years low back pain, buttocks and back of legs Early morning stiffness of 30 mins Naproxen extremely effective in controlling pain Recurrent uveitis – currently quiescent No psoriasis No family history of spondyloarthropathy

8. Examination: Restricted ROM cervical, thoracic and lumbar spine
Reduced neck flexion.
Tender lower thoracic spine
Reduced chest expansion 4 cm Schober’s index 3 cm
Hip examination normal
HLA B27 positive
ESR 23 CRP 26

9. MRI Scan: Thoracic spine: Lumbar spine: Sacroiliac joints:
Corner lesions T 1-2, T 4-5, T 9-11
Florid changes costotransverse joints T 8-9
Lumbar spine:
Corner lesions L2/3 and L4/5
Inflammatory changes facet joints right L4/5 and L5/S1
Sacroiliac joints:
Oedema at the lateral inferior sacral margins

10. Case 2
High BASDAI score No improvement with NSAIDs Treated with TNF inhibitor – etanercept Has been attending NASS group at CUH

11. Case 3
Age 53 year old man Over 10 year history of low back pain Episodic flares Early morning stiffness over 60 minutes History of Crohn’s disease (stable) Chronic bilateral uveitis No psoriasis or family history of spondyloarthropathy

12. Examination Generalised lumbar tenderness but good ROM
Schober’s index 8 cm
Chest expansion 3 cm
HLA B27 negative
ESR 5 CRP 12
BASDAI 6.0 Spinal VAS 6.0

13. MRI spine Cervical spine: Thoracic spine: Sacroiliac joints: Normal
Vertebral corner lesions at several levels
Costovertebral oedema at T8
Sacroiliac joints:
Small amount of oedema at the sacroiliac joint margin bilaterally

14. Management
Current BASDAI 4.9 Ibuprofen PRN Colitis stable for 10 years Suggested regular NSAID - etoricoxib Referred to physiotherapy

15. Case 4
Age 29 year old man Psoriasis 2 years Joint pains for 12 months increasing in severity Wrists, elbows, shoulders, hips, knees, ankles – mild MCPJ TMJ – unable to fully open mouth Severe neck pain No IBD symptoms. No history of uveitis

16. Examination
Unwell and pale Profuse sweating Stiff neck with very limited extension/lateral rotation Reduced EOR thoracic rotational movement Good ROM lumbar spine Restricted painful hips, shoulders and wrists Swollen elbows unable to straighten History of tick bite a few months earlier (Lyme serology negative)

17. Investigations
ESR 18 CRP 100 HLA B27 negative MRI scan: Oedema right costovertebral joint Increased oedema around the inferior margins of SIJ bilaterally Bilateral florid synovitis of both hips with effusions BASDAI 6.7 Spinal VAS 7/10 Diagnosis: Psoriatic spondyloarthopathy with peripheral arthritis

18. Treatment
Ibuprofen switched to Naproxen – no improvement Prednisolone Methotrexate – no improvement TB screening Currently on etanercept: BASDAI 2.8 ESR 2 CRP < 1.0

19. Spondyloarthropathy Axial Spondyloarthritis (Ax-SpA)
Psoriatic arthritis
Reactive arthritis (related to HLA B27)
Enteropathic arthritis (Crohn’s/Ulcerative colitis
JIA ( Enthesitis-related /Psoriatic-related)

20. Axial Spondyloarthritis
Non-radiographic Axial-SpA
(nr-axSpA)
Ankylosing Spondylitis
Active inflammation on MRI suggestive of sacroiliitis +
Other findings
Radiographic (X-ray) changes of sacroiliitis
modified New York criteria

21. Axial Spondyloarthritis
50% of non-radiographic axial-SpA (nr-axSpA) are women
5-12% of nr-axSpA will develop radiographic change over 2 years
15-20% will never develop radiographic sacroiliitis
Predictors of progression to AS:
Male
HLA B27 +ve
Raised inflammatory markers
Significant inflammation on MRI (bone marrow oedema)
Smoking

22. Spondyloarthritis: Facts and figures:
Spondyloarthritis: Facts and figures: State of Musculoskeletal Health 2018
Prevalence
1/200
Average age onset of symptoms
24 years
Age < 45 at disease onset
90-95%
Average delay to diagnosis
8.5
Inflammatory back pain symptoms
89% of nr-axSpA/AS patients
Depression
10% (doctor diagnosed)
Loss of employment
5% (1 year) 20% (10 years) 30% (20 years)

23. ASAS criteria for identifying inflammatory back pain
ASAS criteria for identifying inflammatory back pain Sieper J et al Ann Rheum Dis 2009;68(6):784-8
Back pain for more than 3 months:
Did your back pain start when you were age 40 years or under?
YES/NO
Did your back pain develop gradually?
Does your back pain improve with exercise?
Do you find there is no improvement in your back pain when you rest?
Do you suffer from back pain at night which improves on getting up?
Yes to 4 or more parameters suggest inflammatory back pain 77% sensitive 91.7% specific and warrants further investigation

24. Other symptoms of inflammatory back pain
Good response to NSAIDs
Early morning Stiffness greater than 30 mins
Alternating buttock pain
Waking in the second half of the night with back pain

25. Extra articular manifestations
Enthesitis
Any entheses
Lower limb: Achilles and or plantar fasciitis
14% Ankylosing spondylitis
20% Non-radiographic AxSpA
Uveitis
Most common
20-30%
Risk throughout the course of disease.
Crohn’s/UC
5-10% of patients
Dactylitis
5-6%
Psoriasis 9%
Plaque psoriasis/nail dystrophy
Often present before diagnosis of Ax-SpA

26. HLA B27 HLA B27 is a susceptibility gene
Prognostic feature of axial-SpA
HLA B27 positive
General population 8-9%
Ankylosing spondylitis up to 95%
HLA B27 negative does NOT rule out axial SpA

27. HLA B27 and spondyloarthritis Reveille J Clinical immunology(3rd edition) 2008
HLA B27 prevalence
Ankylosing spondylitis
Up to 95%
Reactive arthritis
70%
Inflammatory bowel disease
50-60%
Psoriatic Spondyloarthritis
60-70%
Psoriatic arthritis
25%
Acute anterior uveitis
50%

28. Diagnosis No formal diagnostic criteria exist for axial SpA
ASAS Classification Criteria can guide
clinical assessment and diagnosis
Other causes of back pain need to be excluded
Look out for ‘Red Flags’
Diagnosis of axial SpA is made by a combination of
clinical features, imaging and blood tests
Negative HLA B27 does not rule out axial SpA
Inflammatory markers may be normal

29. In patients with ≥ 3 months and age at onset < 45 years
ASAS classification criteria for Axial SpA Rudwaleit Met al Ann Rheum Dis 2009;68(6):
In patients with ≥ 3 months and age at onset < 45 years
Sacroiliitis on imaging +
≥ 1 SpA feature
HLA B27 positive
≥ 2 other SpA features

30. Sacroiliitis on imaging
ASAS classification criteria for Axial SpA Rudwaleit Met al Ann Rheum Dis 2009;68(6):
Sacroiliitis on imaging
Active inflammation on MRI suggestive of sacroiliitis
Radiographic (X-ray)
changes of sacroiliitis
modified NY criteria

31. SpA features Inflammatory back pain Arthritis Heel enthesitis Uveitis
Dactylitis
Psoriasis
Crohn’s disease/Ulcerative colitis
Good response to NSAIDs
Family history of SpA
HLA B27 positive
Elevated C-reactive protein
Other causes of back pain have been ruled out

32. Management Patient education on SpA
Lifestyle, smoking, flare management
Clinical outcome measures
BASDAI/Spinal pain score
Physiotherapy/Exercise
Manage comorbidities
Cardiovascular disease, diabetes, osteoporosis
Depression, pulmonary function
Treatment according to NICE guidelines
NSAIDs/Biologics

33. TREATMENT Control of symptoms and inflammation
Prevention of progressive structural damage.
Preserve or normalise function
Monitor for extra-articular manifestations (EAMS)
EAMS should be considered when choosing treatment
Standard therapy:
2 NSAIDs for at least 2 weeks unless contraindicated
Biologics criteria:
BASDAI and spinal VAS ≥ 4 in spite of standard therapy

34. BIOLOGIC DMARDS TNF inhibitors Radiographic and nr-axial SpA
IL-17 inhibitor
Radiographic axial SpA
Adalimumab
Seckukinumab
Certolizumab pegol
Golimumab
Infliximab
Etanercept (fusion protein)

35. SUMMARY
Spondyloarthritis is characterised by a broad spectrum of disorders
associated with HLA B27
Inflammatory back pain is a hallmark symptom of axial-SpA
50% of non-radiographic-SpA are women
Radiographic and non-radiographic axial-SpA have a similar clinical picture
Extra articular manifestations are often associated with axial-SpA
Negative HLA B27 and normal inflammatory markers do
not exclude spondyloarthropathy
High index of suspicion and prompt referral to secondary care is important for early diagnosis, management and to improve outcomes