What is the initial treatment approach for patients with spondyloarthritis and when should they be referred to a rheumatologist?

Initial Treatment Approach for Spondyloarthritis and Rheumatologist Referral Criteria

For patients with spondyloarthritis, NSAIDs are the first-line pharmacological treatment, with referral to a rheumatologist indicated for patients with axial spondyloarthritis who have had back pain before age 45 lasting more than three months and meeting specific clinical criteria. 1

Initial Treatment Approach

Axial Spondyloarthritis

• First-line pharmacological treatment is NSAIDs at the lowest effective dose with continued evaluation and monitoring 1
• NSAIDs should be used at maximum tolerated doses, weighing risks and benefits 1
• If the first NSAID is not effective after 2-4 weeks, another NSAID can be tried 1
• All patients should be referred to a specialist for a structured exercise program 1
• Home exercises are efficacious and should be recommended to all patients 1
• Physical therapy may be more beneficial than home exercises for some patients 1
• Hydrotherapy can be considered for pain management 1

Peripheral Spondyloarthritis

• Corticosteroid injections are first-line for nonprogressive monoarthritis 1
• Standard disease-modifying anti-rheumatic drugs (DMARDs) are indicated for peripheral polyarthritis, oligoarthritis, and persistent monoarthritis 1
• NSAIDs can be added to DMARDs at the lowest effective dose 1
• Short-term injection or oral corticosteroids can be added if NSAIDs are ineffective 1
• For psoriatic arthritis, if a standard DMARD is ineffective at the highest tolerable dose for three months, adding or switching to a different DMARD can be considered 1

When to Refer to a Rheumatologist

Axial Spondyloarthritis

Referral to a rheumatologist is indicated for patients with suspected axial spondyloarthritis who have:

• Back pain starting before age 45 that has lasted more than 3 months 1

PLUS at least 4 of the following criteria:

• Back pain occurring before age 35 1
• Waking at night due to symptoms 1
• Buttock pain 1
• Improvement in pain with movement or within 2 days of taking an NSAID 1
• First-degree relative with spondyloarthritis 1
• Current or previous arthritis, enthesitis, or psoriasis 1

OR 3 of the above criteria PLUS:

• Positive HLA-B27 test 1

Other Indications for Specialist Referral

• Patients with persistently high disease activity despite conventional treatments 1
• Patients with difficulties in daily activities despite NSAID treatment 1
• Immediate referral to an ophthalmologist for symptoms of uveitis (eye pain or redness) 1
• If peripheral spondyloarthritis is diagnosed, radiography of sacroiliac joints should be considered to evaluate for axial involvement 1

Treatment Targets and Monitoring

• Treatment should be guided by a predefined treatment target agreed upon between patient and rheumatologist 1
• Clinical remission/inactive disease should be the major treatment target 1
• Disease activity should be monitored using clinical signs, symptoms, and acute phase reactants 1
• Treatment should be adjusted if the target is not reached 1
• Continuous NSAID use is preferred for patients who respond well and remain symptomatic 1

Important Considerations and Pitfalls

• Early diagnosis and treatment are crucial as there is typically a 5-7 year delay between first symptoms and diagnosis 1
• 75% of patients with axial spondyloarthritis show good response to NSAIDs within 48 hours, compared to only 15% with mechanical back pain - this can be a helpful diagnostic clue 1
• Less than 25% of patients achieve complete symptom control with NSAIDs alone, highlighting the importance of timely specialist referral 2
• Approximately 75% of patients eventually require biologic drugs (TNF inhibitors, IL-17 inhibitors) or JAK inhibitors to control symptoms and prevent structural damage 2
• Do not rule out spondyloarthritis based solely on a negative HLA-B27 test or normal inflammatory markers 1
• Analgesics like paracetamol and opioids should only be considered for residual pain after recommended treatments have failed 1

By following this structured approach to the initial management of spondyloarthritis and using clear referral criteria, primary care physicians can ensure timely diagnosis and appropriate treatment for these patients, potentially improving long-term outcomes.