Axial Spondyloarthritis Diagnosis and Management
Clinical Diagnosis
- The American College of Radiology suggests that morning stiffness worse in the morning and improving with movement is pathognomonic for inflammatory rather than mechanical back pain 1, 2
- The American College of Radiology recommends that chronic duration of symptoms (months) meets the typical criterion of ≥3 months 1, 2, 3
- The American College of Radiology notes that right-sided pain with diffuse lower back stiffness suggests sacroiliac joint involvement, which is the initial site of inflammation in axSpA 1, 3
- The pattern of pain improving with activity but worsening with rest distinguishes this from mechanical causes like disc herniation 1
Diagnostic Workup
- The Journal of the American College of Radiology recommends starting with plain radiographs of the sacroiliac joints and lumbar spine as first-line imaging 2, 3
- The Journal of the American College of Radiology suggests that MRI of sacroiliac joints is indicated if radiographs are negative but clinical suspicion remains high 2, 3
- The Annals of the Rheumatic Diseases notes that HLA-B27 positivity increases diagnostic likelihood but is neither necessary nor sufficient for diagnosis 4
Treatment Algorithm
- The American College of Rheumatology recommends NSAIDs at full anti-inflammatory doses as first-line therapy 1, 5
- The American College of Rheumatology suggests that physical therapy and exercise should be used to maintain mobility and function 1, 5
- The Annals of the Rheumatic Diseases notes that biologic DMARDs or JAK inhibitors are indicated when NSAIDs fail to control symptoms 1, 5
- The American College of Rheumatology recommends that treatment goals should include a BASDAI score <3 or reduction by 2 points, or ASDAS inactive disease (<1.3) 5, 6, 7