Dr. Marina Magrey, a physician from the MetroHealth System, in Cleveland, OH, reviews her article appearing in the November 2020 issue of Mayo Clinic Proceedings, which gives a snapshot of the condition axial-spondyloarthritis for the primary care physician so they can recognize the symptoms and offer a treatment approach for this unique cause of low back pain – one of the leading reasons patients seek help from their medical care team. Frequently, there can be delays of several years between the onset of symptoms and the correct diagnosis. Available at:
Hello i am dr marina margaret the lead author of the review titled recognizing axial spondyloarthritis a guide for primary care before we begin please see my disclosure information here back pain is a common health problem affecting 80 to 85 percent of people at some point in their lifetime and is second leading symptom prompting a visit to a primary care
Physician approximately 20 percent of people aged 20 to 59 years have chronic back pain and the prevalence increases with age one important but under recognized cause of chronic back pain is axial spondyloarthritis an inflammatory rheumatic disease that predominantly involves the spine and the sacroiliac joints axial spondyloarthritis is associated with a
Characteristic pattern of back pain that’s referred to as inflammatory back pain the aims of this review are to introduce the concept of inflammatory back pain and other features salient to early detection of axial spondyloarthritis and to discuss strategy for identification of patients with axial spa among patients with chronic back pain in primary care
Setting axial spondyloarthritis is a disease predominantly affecting the axial skeleton but also involves peripheral joints and theses extra articular organs such as skin eyes and intestines axial spa typically develops in individuals younger than 45 years and has a peak age of onset between 20 and 30 years chronic inflammation in the sacroiliac joints and
The spine results in back pain and stiffness and can over time lead to pathological new bone formation structural damage and ultimately fusion of sacroiliac joints and the spine in some patients the concept of axial spondyloarthritis which includes a.s or ankylosing spondylitis was first established by a set of classification criteria developed in 2009 by
The assessment of spondyloarthritis international society asas according to the asa’s classification criteria patients who experience chronic back pain before the age of 45 years have axial spa if they have imaging evidence of sacroiliitis by mri or radiography plus at least one spa feature or are positive for hla b27 and have two or more other spa features
Features of spondyloarthritis include inflammatory back pain peripheral inflammatory arthritis anthocytus uveitis dactylitis psoriasis crohn’s disease or ulcerative colitis good response to non-steroidal anti-inflammatory drugs family history of spondyloarthritis hoa b27 positivity and elevated c-reactive protein patients with axial spondyloarthritis who have
Obvious structural changes on the radiographs of the sacroiliac joints indicating sacroiliitis are classified as having radio radiographic axial spondyloarthritis which is for all practical purpose the same as traditional ankylosing spondylitis patients who have axial spa based on symptoms and other clinical features but lack obvious radiographic changes of
Sacroiliitis and non-radiographic axial spa clinical judgment is considered the criteria standard for diagnosis of aes and axial spondyloarthritis the hallmark feature of an axial spondyloarthritis is inflammatory back pain which is characterized by insidious onset of chronic pain lasting more than three months before the age of 40 to 45 years patients usually
Wake up in the second half of the night due to the back pain the pain improves with physical activity but not rest associated with morning stiffness persisting for more than 30 minutes and usually has good response to non-steroidal anti-inflammatory drugs many of these characteristics of inflammatory back pain contrast with those of mechanical back pain patients
With axial spondyloarthritis also frequently have extra articular manifestations like uveitis psoriasis and inflammatory bowel disease and additional comorbidities associated with axial spa are fatigue osteoporosis cardiovascular disease and sleep apnea the true prevalence of axial spondyloarthritis is unknown and large differences between diagnostic prevalence
And population prevalence have been reported which may reflect substantial under diagnosis in routine clinical practice the average delay between symptom onset and diagnosis is estimated to be five to seven years with evidence that delay can be significantly longer in women than in men several factors may contribute to this delay in diagnosis including the
High prevalence of back pain most commonly due to mechanical etiologies in the general population the lack of specific physical exam findings in patients with early axial spa and absence of extraspinal manifestations have been reported to impair early diagnosis the lack of biomarkers unique to axial spa younger age at onset and gradual disease onset may also
Contribute to delayed referral for evaluation by a rheumatologist instead patients may be referred to and treated by orthopedist physiatrist chiropractor and other providers in an attempt to relieve symptoms paradoxically a good response to ancients may also contribute to a delay in diagnosis because further evaluation may not be pursued when patients report
Improved symptoms with nsaids lack of access to rheumatologists inadequate referral guidelines and long waiting times may also contribute to the diagnostic and therapeutic delays in some areas screening and referral strategies have been developed to help primary care physicians determine whether axial spondyloarthritis should be considered and to guide the
Initial evaluation for suspected axial spa including support in making the decision whether to refer the patients to a rheumatologist for example according to a strategy proposed by asas patients with chronic back pain for at least three months with an onset at age 45 years or before should be referred to a rheumatologist for other further evaluation if they
Have any one of the following parameters inflammatory back pain hoa b27 positivity imaging evidence of sacroiliitis peripheral manifestations such as arthritis enthesitis or dactylitis extra-articular manifestations such as psoriasis inflammatory bowel disease and or uveitis family history of axial spondyloarthritis good response to nsaids or elevated acute
Phase reactants although the optimal referral strategy may depend on details of the healthcare environment axial spondyloarthritis should also be considered in the differential diagnosis or back chronic back pain particularly in younger patients it is critical that primary care physicians screen for inflammatory back pain and other axial spot features and
Refer patients with suspicion for axial spa to a rheumatologist for further evaluation the goals of treatment for axial spy include alleviating symptoms optimizing function and preventing structural damage to the spine the initial medication class for treatment of active axial spa is non-steroidal anti-inflammatory therapy treatment with the biologic drug is
Indicated for ac2 axial spa if a patient is intolerant to and said or has an inadequate response to two or more nsaids at a therapeutic dose for two weeks each several tumor necrosis factor and interneukin 17a inhibitors are available for the treatment of axial spondyloarthritis the selection of biologic therapies may be influenced by comorbidities availability
Including insurance formularies response to prayer treatment if previously treated with a biologic drug patient preference and other factors neither traditional disease modifying drugs such as methotrexate or sulfasalazine nor systemic glucocorticoids are recommended for axial manifestation because there is little evidence of their clinical benefit in summary
Axial spondyloarthritis is a chronic inflammatory disease that causes back pain and stiffness reduces mobility and decreases the quality of life axial spondyloarthritis affects about one percent of the us population but is currently under diagnosed patients without a diagnosis are unlikely to receive appropriate treatment and may experience worse symptoms and
Poor outcomes in the long term as the first line providers of care for patients with back pain primary care physicians must be aware of the clinical features that suggest exhale spondyloarthritis particularly in younger patients raising awareness of all the manifestations of axial spondyloarthritis among primary care physicians should improve the recognition
Of the disease and facilitate the timely referral of appropriate patients to rheumatologists for early diagnosis and effective management we hope you found this presentation from the content of our website valuable our journal’s mission is to promote the best interests of patients by advancing the knowledge and professionalism of the physician community if
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Recognizing Axial Spondyloarthritis By Mayo Proceedings
