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Identifying, Referring and Managing Spondyloarthritis

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Identifying, Referring and Managing Spondyloarthritis = Non-steroidal anti- Identifying, referring and managing spondyloarthritis NSAIDs inflammatory drugs Standard Biological = Disease-modifying Visual summary of NICE guidelines DMARDs DMARDs antirheumatic drugs Spondyloarthritis can have Musculoskeletal Associated conditions Risk factors diverse symptoms and be symptoms Uveitis Psoriasis Recent genitourinary difficult to identify. The infection presence of these key Joint pain in fingers or toes Refer acute Including indicators might prompt anterior uveitis Family history of Chronic back pain psoriatic spondyloarthritis you to continue through urgently to an nail the more detailed Enthesitis Dactylitis ophthalmologist* symptoms assessments below. Family history of psoriasis Suspected axial spondyloarthritis Suspected peripheral spondyloarthritis Dactylitis Enthesitis Low back pain Suspected new- Inflammation of onset inflammatory Started before age 45 Lasting longer than 3 months Inflammation of entheses, fingers or toes often in the heel arthritis Assess for referral criteria No apparent Multiple A concurrent or Low back pain that started Current or past Improvement within Persistent or or before the age of 35 years enthesitis 48 hours of taking mechanical cause sites historic condition NSAIDs Waking during the second half of Current or past the night because of symptoms arthritis Improvement with movement Back pain without apparent cause Current or past uveitis psoriasis A first-degree relative with Current or past Gastrointestinal genitourinary infection Inflammatory bowel disease spondyloarthritis psoriasis Buttock pain A first-degree relative with spondyloarthritis or psoriasis Gout 2 or fewer Exactly 3 4+ referral Usually + referral critera referral criteria criteria managed in Specialist primary care Acute CPP (calcium + pyrophosphate) arthritis referral Advise repeat Rheumatoid arthritis assessments if new HLA-B27 test Refer to a rheumatologist for + signs, symptoms or risk specialist diagnostic assessment - Negative + Positive factors develop. No additional features Diagnosis No single test can reliably rule out spondyloarthritis. Diagnosis in specialist in specialist care will rest on multiple setting signs, symptoms, and test results HLA–B27 test results Imaging, using inflammatory Managing axial spondyloarthritis back pain protocol Managing peripheral spondyloarthritis Clinical features MRI X-ray Pharmacological Non-pharma Pharmacological Non-pharma management management management management Validated SpA criteria may Unless skeleton help to guide judgement has not fully Consider referral to: matured. For people NSAIDs Physiotherapy Peripheral polyarthritis with psoriatic Refer to a specialist Physiotherapy Lowest effective dose, or arthritis, with appropriate clinical physiotherapist to Oligoarthritis which does assessment and monitoring start a structured not respond Occupational therapy exercise programme Non- or to 2 or more progressive Progressive standard Therapist After 2–4 weeks, if maximum monoarthritis monoarthritis tolerated dose is ineffective Also consider referral to: DMARDs Therapist Podiatrist Occupational Hydrotherapy Standard Biological Consider therapy Orthotist Corticosteroid Orthotist Etc. DMARDs DMARDs Switching to injections a different Switch Podiatrist Etc. to or add To manage pain + + Short term NSAID Steroid Oral For people having Biological adjunctive NSAIDs injections steroids difficulty with daily DMARDs For people having difficulty with daily activities therapy activities Managing ares Offer advice on possibility of: Consider developing a flare management plan, with information on: Seek specialist advice as needed, particularly for: There is no “one size fits all” approach to flare Extra- Access to care Pain & fatigue Exercises People with comorbidities management, as patients’ Flare Self Managing Recurrent People taking articular (named individual) management or experiences vary and episodes care: Stretching impact symptoms persistent Biological multiple approaches on daily Acute uveitis flares Potential medicine changes Joint protection flares DMARDs may be appropriate life (Ophthalmology input) For people with axial spondyloarthritis: Long term management Take into account adverse Skin cancer Cardiovascular effects associated with: While there is little evidence to Osteoporosis Fractures support long term management Advise people on risk Discuss risk factors of skin cancer for those for cardiovascular Consider osteoporosis Advise people that they strategies, there are a number of NSAIDs Standard Biological potential issues to be aware of DMARDs DMARDs using TNF alpha inhibitors comorbidities assessments every two years may be prone to fractures * Ophthalmologists may refer people directly to a rheumatologist, after following the DUET algorithm (see http://dx.doi.org/10.1136/annrheumdis-2014-205358). © 2017 BMJ Publishing group Ltd. The production and Supported by UCB through Read the full distribution of this an educational grant. UCB http://bmj.co/spond Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, article online conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of poster was supported has no editorial control on treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: http://www.bmj.com/company/legal-information/ by NASS the contents.
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