Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Spondyloarthritis is a group of inflammatory conditions that have a range of manifestations. Spondyloarthritis may be predominantly:

  • axial:

    • radiographic axial spondyloarthritis (ankylosing spondylitis)

    • non-radiographic axial spondyloarthritis or

  • peripheral:

    • psoriatic arthritis

    • reactive arthritis

    • enteropathic spondyloarthritis.

People with predominantly axial spondyloarthritis may have additional peripheral symptoms, and vice versa.

Axial presentations of spondyloarthritis are often misdiagnosed as mechanical low back pain, leading to delays in access to effective treatments. Peripheral presentations are often seen as unrelated joint or tendon problems, and can be misdiagnosed because problems can move around between joints.

1.1 Recognition and referral in non-specialist care settings

1.1.1

Do not rule out the possibility that a person has spondyloarthritis solely on the presence or absence of any individual sign, symptom or test result.

Suspecting spondyloarthritis

1.1.2

Recognise that spondyloarthritis can have diverse symptoms and be difficult to identify, which can lead to delayed or missed diagnoses. Signs and symptoms may be musculoskeletal (for example, inflammatory back pain, enthesitis and dactylitis) or extra-articular (for example, uveitis and psoriasis [including psoriatic nail symptoms]). Risk factors include recent genitourinary infection and a family history of spondyloarthritis or psoriasis.

1.1.3

Be aware that axial and peripheral spondyloarthritis may be missed, even if the onset is associated with established comorbidities (for example, uveitis, psoriasis, inflammatory bowel disease [Crohn's disease or ulcerative colitis], or a gastrointestinal or genitourinary infection).

1.1.4

Be aware that axial spondyloarthritis:

  • affects a similar number of women as men

  • can occur in people who are human leukocyte antigen B27 (HLA‑B27) negative

  • may be present despite no evidence of sacroiliitis on a plain film X‑ray.

Referral for suspected axial spondyloarthritis

1.1.5

If a person has low back pain that started before the age of 45 years and has lasted for longer than 3 months, refer the person to a rheumatologist for a spondyloarthritis assessment if 4 or more of the following additional criteria are also present:

  • low back pain that started before the age of 35 years (this further increases the likelihood that back pain is due to spondyloarthritis compared with low back pain that started between 35 and 44 years)

  • waking during the second half of the night because of symptoms

  • buttock pain

  • improvement with movement

  • improvement within 48 hours of taking non-steroidal anti-inflammatory drugs (NSAIDs)

  • a first-degree relative with spondyloarthritis

  • current or past arthritis

  • current or past enthesitis

  • current or past psoriasis.

    If exactly 3 of the additional criteria are present, perform an HLA‑B27 test. If the test is positive, refer the person to a rheumatologist for a spondyloarthritis assessment.

1.1.6

If the person does not meet the criteria in recommendation 1.1.5 but clinical suspicion of axial spondyloarthritis remains, advise the person to seek repeat assessment if new signs, symptoms or risk factors listed in recommendation 1.1.5 develop. This may be especially appropriate if the person has current or past inflammatory bowel disease (Crohn's disease or ulcerative colitis), psoriasis or uveitis (see recommendation 1.1.12 for guidance on referral for immediate [same‑day] ophthalmological assessment for people with acute anterior uveitis).

Referral for suspected psoriatic arthritis and other peripheral spondyloarthritides

1.1.9

Refer people with dactylitis to a rheumatologist for a spondyloarthritis assessment.

1.1.10

Refer people with enthesitis without apparent mechanical cause to a rheumatologist for a spondyloarthritis assessment if:

  • it is persistent or

  • it is in multiple sites or

  • any of the following are also present:

    • back pain without apparent mechanical cause

    • current or past uveitis (see recommendation 1.1.12 for guidance on immediate [same‑day] ophthalmological assessment for people with acute anterior uveitis)

    • current or past psoriasis

    • gastrointestinal or genitourinary infection

    • inflammatory bowel disease (Crohn's disease or ulcerative colitis)

    • a first-degree relative with spondyloarthritis or psoriasis.

Recognising psoriasis

1.1.11

If a person with suspected spondyloarthritis has signs or symptoms of undiagnosed psoriasis, follow the recommendations in the NICE guideline on psoriasis.

Referral for suspected acute anterior uveitis

1.1.12

Refer people for an immediate (same‑day) ophthalmological assessment if they have symptoms of acute anterior uveitis (for example, eye pain, eye redness, sensitivity to light or blurred vision).

Case-finding in people with acute anterior uveitis

1.1.13

Ophthalmologists should ask people with acute anterior uveitis whether they have:

  • consulted their GP about joint pains or

  • experienced low back pain that started before the age of 45 years and has lasted for longer than 3 months.

1.1.14

If the person meets either of the criteria in recommendation 1.1.13, establish whether they have psoriasis or skin complaints that appear psoriatic on physical examination.

  • If they do, refer the person to a rheumatologist for a spondyloarthritis assessment.

  • If they do not, perform an HLA‑B27 test. If the test is positive, refer the person to a rheumatologist for a spondyloarthritis assessment.

1.2 Diagnosing spondyloarthritis in specialist care settings

Diagnostic criteria for suspected spondyloarthritis

1.2.1

In specialist care settings, consider using validated spondyloarthritis criteria to guide clinical judgement when diagnosing spondyloarthritis. Examples include:

  • general spondyloarthritis criteria:

    • Amor

    • European Spondyloarthropathy Study Group (ESSG)

  • axial spondyloarthritis criteria:

    • Assessment of Spondyloarthritis International Society (ASAS; axial)

    • Berlin

    • Rome

    • modified New York

  • peripheral spondyloarthritis criteria:

    • ASAS (peripheral)

    • Classification of Psoriatic Arthritis (CASPAR)

    • French Society of Rheumatology (reactive arthritis).

1.2.2

Do not rule out a diagnosis of spondyloarthritis solely on the basis of a negative HLA‑B27 result.

1.2.3

Do not rule out a diagnosis of spondyloarthritis if a person's C‑reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are normal.

Imaging for suspected axial spondyloarthritis

Initial investigation using X‑ray
1.2.4

Offer plain film X‑ray of the sacroiliac joints for people with suspected axial spondyloarthritis, unless the person is likely to have an immature skeleton.

1.2.5

Diagnose radiographic axial spondyloarthritis (ankylosing spondylitis) if the plain film X‑ray shows sacroiliitis meeting the modified New York criteria (bilateral grade 2–4 or unilateral grade 3–4 sacroiliitis).

1.2.6

If the plain film X‑ray does not show sacroiliitis meeting modified New York criteria (bilateral grade 2–4 or unilateral grade 3–4 sacroiliitis), or an X‑ray is not appropriate because the person's skeleton is not fully mature, request unenhanced MRI using an inflammatory back pain protocol.

Subsequent investigation using MRI
1.2.7

Radiologists receiving a request for an inflammatory back pain MRI should perform short T1 inversion recovery (STIR) and T1 weighted sequences of the whole spine (sagittal view), and sacroiliac joints (coronal oblique view).

1.2.8

Use the ASAS/Outcome Measures in Rheumatology (OMERACT) MRI criteria to interpret the MRI as follows:

  • If the MRI meets the ASAS/OMERACT MRI criteria:

    • diagnose non-radiographic axial spondyloarthritis.

  • If the MRI does not meet the ASAS/OMERACT MRI criteria:

    • do not exclude the possibility of axial spondyloarthritis

    • consider specialist musculoskeletal radiology review if there is disparity between the clinical suspicion and imaging findings, particularly in people with an immature skeleton

    • offer an HLA‑B27 test if it has not already been done. If positive, base the diagnosis of non-radiographic axial spondyloarthritis on clinical features, for example, using the clinical 'arm' of the ASAS axial classification criteria.

1.2.9

If a diagnosis of axial spondyloarthritis cannot be confirmed and clinical suspicion remains high, consider a follow‑up MRI.

Other types of imaging for diagnosing axial spondyloarthritis
1.2.10

Do not offer scintigraphy for people with suspected axial spondyloarthritis.

Imaging for suspected psoriatic arthritis and other peripheral spondyloarthritides

1.2.11

Offer plain film X‑ray of symptomatic hands and feet for people with suspected peripheral spondyloarthritis in these areas.

1.2.12

If a diagnosis cannot be made from the plain film X‑ray, consider ultrasound of:

  • the hands and feet to assess for joint involvement

  • suspected enthesitis sites.

1.2.13

Consider plain film X‑rays, ultrasound and/or MRI of other peripheral and axial symptomatic sites.

1.2.14

Interpret a positive HLA‑B27 result as increasing the likelihood of peripheral spondyloarthritis.

1.2.15

If a diagnosis of peripheral spondyloarthritis is confirmed, offer plain film X‑ray of the sacroiliac joints to assess for axial involvement, even if the person does not have any symptoms.

Antibody testing for suspected reactive arthritis

1.2.16

Do not routinely test for infective antibody status to diagnose reactive arthritis in people with a history of gastrointestinal infection.

1.3 Information and support

Information about spondyloarthritis

1.3.1

Provide people with spondyloarthritis, and their family members or carers (as appropriate), with information that is:

1.3.2

Provide explanations and information about spondyloarthritis, for example:

  • what spondyloarthritis is

  • diagnosis and prognosis

  • treatment options (pharmacological and non-pharmacological), including possible side effects

  • likely symptoms and how they can be managed

  • flare episodes and extra-articular symptoms

  • self-help options

  • opportunities for people with spondyloarthritis to be involved in research

  • which healthcare professionals will be involved with the person's care and how to get in touch with them

  • information about employment rights and ability to work

  • local support groups, online forums and national charities, and how to get in touch with them.

Information about disease flares

1.3.3

Advise people with spondyloarthritis about the possibility of experiencing flare episodes and extra-articular symptoms.

1.3.4

Consider developing a flare management plan that is tailored to the person's individual needs, preferences and circumstances.

1.3.5

When discussing any flare management plan, provide information on:

  • access to care during flares (including details of a named person to contact [for example, a specialist rheumatology nurse])

  • self-care (for example, exercises, stretching and joint protection)

  • pain and fatigue management

  • potential changes to medicines

  • managing the impact on daily life and ability to work.

1.4 Pharmacological management of spondyloarthritis

Axial spondyloarthritis

NSAIDs
1.4.1

Offer NSAIDs at the lowest effective dose to people with pain associated with axial spondyloarthritis, and think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment.

1.4.2

If an NSAID taken at the maximum tolerated dose for 2–4 weeks does not provide adequate pain relief, consider switching to another NSAID.

Biological DMARDs – adalimumab, certolizumab pegol, etanercept, golimumab and infliximab for the treatment of ankylosing spondylitis and non-radiographic axial spondyloarthritis
1.4.3

Adalimumab, certolizumab pegol, etanercept, golimumab and infliximab are recommended, within their marketing authorisations, as options for treating severe active ankylosing spondylitis in adults whose disease has responded inadequately to, or who cannot tolerate, NSAIDs. Infliximab is recommended only if treatment is started with the least expensive infliximab product. People currently receiving infliximab should be able to continue treatment with the same infliximab product until they and their NHS clinician consider it appropriate to stop.
[This recommendation is from NICE's technology appraisal guidance on TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis.]

1.4.5

The choice of treatment should be made after discussion between the clinician and the patient about the advantages and disadvantages of the treatments available. This may include considering associated conditions such as extra-articular manifestations. If more than 1 treatment is suitable, the least expensive (taking into account administration costs and patient access schemes) should be chosen.
[This recommendation is from NICE's technology appraisal guidance on TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis.]

1.4.6

The response to adalimumab, certolizumab pegol, etanercept, golimumab or infliximab treatment should be assessed 12 weeks after the start of treatment. Treatment should only be continued if there is clear evidence of response, defined as:

Biological DMARDs – secukinumab for the treatment of ankylosing spondylitis
1.4.9

Secukinumab is recommended, within its marketing authorisation, as an option for treating active ankylosing spondylitis in adults whose disease has responded inadequately to conventional therapy (NSAIDs or TNF‑alpha inhibitors). The drug is recommended only if the company provides it with the discount agreed in the patient access scheme.
[This recommendation is from NICE's technology appraisal guidance on secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors.]

Psoriatic arthritis and other peripheral spondyloarthritides

Non-biological therapies
1.4.12

Consider local corticosteroid injections as monotherapy for non-progressive monoarthritis.

1.4.13

Offer standard disease-modifying anti-rheumatic drugs (DMARDs) to people with:

  • peripheral polyarthritis

  • oligoarthritis

  • persistent or progressive monoarthritis associated with peripheral spondyloarthritis.

1.4.14

When deciding which standard DMARD to offer, take into account:

  • the person's needs, preferences and circumstances (such as pregnancy planning and alcohol consumption)

  • comorbidities such as uveitis, psoriasis and inflammatory bowel disease

  • disease characteristics

  • potential side effects.

1.4.15

If a standard DMARD taken at the maximum tolerated dose for at least 3 months does not provide adequate relief from symptoms, consider switching to or adding another standard DMARD.

1.4.16

Consider NSAIDs as an adjunct to standard DMARDs or biological DMARDs to manage symptoms. Use oral NSAIDs at the lowest effective dose for the shortest possible period of time, and think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment.

1.4.17

If NSAIDs do not provide adequate relief from symptoms, consider steroid injections (local or intramuscular) or short-term oral steroid therapy as an adjunct to standard DMARDs or biological DMARDs to manage symptoms.

1.4.18

If extra-articular disease is adequately controlled by an existing standard DMARD but peripheral spondyloarthritis is not, consider adding another standard DMARD.

Targeted synthetic DMARDs – apremilast for the treatment of psoriatic arthritis
Biological DMARDs – etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
1.4.20

Etanercept, infliximab and adalimumab are recommended for the treatment of adults with active and progressive psoriatic arthritis when the following criteria are met.

1.4.22

Etanercept, adalimumab or infliximab treatment should be discontinued in people whose psoriatic arthritis has not shown an adequate response using the Psoriatic Arthritis Response Criteria (PsARC) at 12 weeks. An adequate response is defined as an improvement in at least 2 of the 4 PsARC criteria (1 of which has to be joint tenderness or swelling score) with no worsening in any of the 4 criteria. People whose disease has a Psoriasis Area and Severity Index (PASI) 75 response at 12 weeks but whose PsARC response does not justify continuation of treatment should be assessed by a dermatologist to determine whether continuing treatment is appropriate on the basis of skin response (see NICE's technology appraisal guidance on etanercept and efalizumab for the treatment of adults with psoriasis [TA103], infliximab for the treatment of adults with psoriasis [TA134] and adalimumab for the treatment of adults with psoriasis [TA146] for guidance on the use of TNF inhibitors in psoriasis).
[This recommendation is from NICE's technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis.]

Biological DMARDs – golimumab for the treatment of psoriatic arthritis
1.4.24

Golimumab is recommended as an option for the treatment of active and progressive psoriatic arthritis in adults only if:

1.4.25

When using the PsARC (as set out in NICE technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis [TA199] (see recommendations 1.4.20–1.4.23 in this guideline), healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect a person's responses to components of the PsARC and make any adjustments they consider appropriate.
[This recommendation is from NICE's technology appraisal guidance on golimumab for the treatment of psoriatic arthritis.]

Biological DMARDs – ustekinumab for the treatment of psoriatic arthritis
1.4.26

Ustekinumab is recommended as an option, alone or in combination with methotrexate, for treating active psoriatic arthritis in adults only when:

1.4.27

Ustekinumab treatment should be stopped if the person's psoriatic arthritis has not shown an adequate response using the PsARC at 24 weeks. An adequate response is defined as an improvement in at least 2 of the 4 criteria (1 of which must be joint tenderness or swelling score), with no worsening in any of the 4 criteria. As recommended in NICE technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis (see recommendations 1.4.20–1.4.23 in this guideline), people whose disease has a PASI 75 response but whose PsARC response does not justify continuing treatment should be assessed by a dermatologist to determine whether continuing treatment is appropriate on the basis of skin response (see NICE technology appraisal guidance on ustekinumab for the treatment of adults with moderate to severe psoriasis).
[This recommendation is from NICE's technology appraisal guidance on ustekinumab for treating active psoriatic arthritis.]

Reactive arthritis

Antibiotics
1.4.30

After treating the initial infection, do not offer long-term (4 weeks or longer) treatment with antibiotics solely to manage reactive arthritis caused by a gastrointestinal or genitourinary infection.

1.5 Non-pharmacological management of spondyloarthritis

1.5.1

Refer people with axial spondyloarthritis to a specialist physiotherapist to start an individualised, structured exercise programme, which should include:

  • stretching, strengthening and postural exercises

  • deep breathing

  • spinal extension

  • range of motion exercises for the lumbar, thoracic and cervical sections of the spine

  • aerobic exercise.

1.5.2

Consider hydrotherapy as an adjunctive therapy to manage pain and maintain or improve function for people with axial spondyloarthritis.

1.5.3

Consider a referral to a specialist therapist (such as a physiotherapist, occupational therapist, hand therapist, orthotist or podiatrist) for people with spondyloarthritis who have difficulties with any of their everyday activities. The specialist therapist should:

  • assess people's needs

  • provide advice about physical aids

  • arrange periodic reviews to assess people's changing needs.

1.6 Surgery for spondyloarthritis

1.6.1

Do not refer people with axial spondyloarthritis to a complex spinal surgery service to be assessed for spinal deformity correction unless the spinal deformity is:

  • significantly affecting their quality of life and

  • severe or progressing despite optimal non-surgical management (including physiotherapy).

1.6.2

If a person with axial spondyloarthritis presents with a suspected spinal fracture, refer them to a specialist to confirm the spinal fracture and carry out a stability assessment. After the stability assessment, the specialist should refer people with a potentially unstable spinal fracture to a spinal surgeon.

1.7 Managing flares

1.7.1

Manage flares in either specialist care or primary care depending on the person's needs.

1.7.2

When managing flares in primary care, seek advice from specialist care as needed, particularly for people who:

  • have recurrent or persistent flares

  • are taking biological DMARDs

  • have comorbidities that may affect treatment or management of flares.

1.7.3

Be aware that uveitis can occur during flare episodes. See recommendation 1.1.12 for guidance on immediate (same‑day) ophthalmological assessment for people with acute anterior uveitis.

1.8 Long-term complications

1.8.2

Take into account the adverse effects associated with NSAIDs, standard DMARDs and biological DMARDs when monitoring spondyloarthritis in primary care.

1.8.3

Advise people that there may be a greater risk of skin cancer in people treated with TNF‑alpha inhibitors.

1.8.4

Discuss risk factors for cardiovascular comorbidities with all people with spondyloarthritis.

1.8.5

Consider regular osteoporosis assessments (every 2 years) for people with axial spondyloarthritis. Be aware that bone mineral density measures may be elevated on spinal dual‑energy X‑ray absorptiometry (DEXA) due to the presence of syndesmophytes and ligamentous calcification, whereas hip measurements may be more reliable.

1.8.6

Advise people with axial spondyloarthritis that they may be prone to fractures, and should consult a healthcare professional following falls or physical trauma, particularly in the event of increased musculoskeletal pain.

1.9 Organisation of care

Coordinating care across settings

1.9.1

Commissioners should ensure that local arrangements are in place to coordinate care for people across primary and secondary (specialist) care. These should cover:

  • prescribing NSAIDs and standard DMARDs

  • monitoring NSAIDs, standard DMARDs and biological DMARDs

  • managing flares

  • ensuring prompt access to specialist rheumatology care when needed

  • ensuring prompt access to other specialist services to manage comorbidities and extra-articular symptoms.

1.9.2

Ensure that people with spondyloarthritis have access to specialist care in primary or secondary care settings throughout the disease course to ensure optimal long-term spondyloarthritis management (see section 1.7 for arrangements for managing flares).

1.9.3

Ensure that there is effective communication and coordination between all healthcare professionals involved in the person's care, particularly if the person has comorbidities or extra-articular symptoms.

1.9.4

Ensure that there is communication and coordination between rheumatology and other relevant specialities (such as dermatology, gastroenterology and ophthalmology). This is particularly important for people who:

  • are already receiving standard DMARDs or biological DMARDs for another condition

  • need to start taking standard DMARDs or biological DMARDs for another condition.