Changes

March 2024 — minor update. Some minor formatting changes have been made to this topic. 

Update

Goals

To support primary health care professionals to:

• Know when to suspect spondyloarthritis or psoriatic arthropathy.
• Offer appropriate initial and ongoing management, including referral to rheumatology for confirmation of diagnosis and implementation of treatment.
• Follow-up people with spondyloarthritis or psoriatic arthropathy as part of a shared-care arrangement with specialist rheumatology services.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

NICE quality standards

The following NICE Quality Statements may be relevant to the management of people with spondyloarthritis or psoriatic arthropathy:

• Adults with suspected axial or peripheral spondyloarthritis are referred to a rheumatologist.
• Adults with suspected axial spondyloarthritis and an X‑ray that does not show sacroiliitis have an MRI using an inflammatory back pain protocol.
• Adults with axial spondyloarthritis are referred to a specialist physiotherapist for a structured exercise programme.
• Adults with spondyloarthritis are given information about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.
• People with psoriasis are offered an assessment of the impact of the disease on physical, psychological, and social wellbeing at diagnosis and when response to treatment is assessed.
• Adults with severe psoriasis are offered a cardiovascular risk assessment at diagnosis and at least once every 5 years.
• People with psoriasis having treatment are offered an annual assessment for psoriatic arthritis.
• People with psoriasis receiving systemic therapy are monitored in accordance with locally agreed protocols.

[NICE, 2013; NICE, 2018]

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

What is it?

• Spondyloarthritis is a term describing a group of clinically heterogeneous inflammatory rheumatologic conditions.
  • It may be predominantly axial, affecting the sacroiliac joints and the spine, or predominantly peripheral.
  • People with one predominant subtype often experience features of the other subtype. 
• Most people with spondyloarthritis have either psoriatic arthritis or axial spondyloarthritis.
  • Psoriatic arthritis is a predominantly peripheral subtype of spondyloarthritis that affects people with psoriasis.
  • Axial spondyloarthritis primarily affects the axial skeleton and includes non-radiographic axial spondyloarthritis, as well as radiographic axial spondyloarthritis (known as Ankylosing spondylitis) — where sacroiliitis is visible on an X-ray.
• Other subtypes of spondyloarthritis include enteropathic arthritis (joint manifestations in people with inflammatory bowel disease) and reactive arthritis (following specific types of infection).

[NICE, 2017a; Ramiro, 2023]

How common is it?

• Axial spondyloarthritis was observed at a prevalence of 0.66% (using modified New York criteria) in a UK cross-sectional cohort study of 505 people in an adult primary care population with low back pain, and 0.15% in the general adult primary care population.
  • Studies have shown that 14–16% of community patients with chronic low back pain under the age of 45 years have axial spondyloarthritis.
• Psoriatic arthritis was observed in a US study at a prevalence of 0.25% in the general population. At least 25% of people with psoriasis will develop psoriatic arthritis. 
• Reactive arthritis occurs in up to 4% of people with a recent urogenital infection, and up to 15% of people following a gastrointestinal infection.
• Enteropathic arthritis signs and symptoms were assessed in a large meta-analysis of people with inflammatory bowel disease. 10% reported sacroiliitis and 13% reported peripheral joint manifestations. Rates of both were higher in people with Crohn's disease compared to those with ulcerative colitis.

[Hamilton, 2015; van Hoeven, 2015; Karreman, 2017; NICE, 2017a; Springate, 2017; Alinaghi, 2019; Baraliakos, 2020; BMJ Best Practice, 2023; Cheeti, 2023; Ramiro, 2023]

What causes it?

The causes of spondyloarthritis are thought to be multifactorial and include:

• Genetic factors:
  • More than 90% heritability has been estimated for axial spondyloarthritis; the most important genetic risk factor is human leukocyte antigen B27 (HLA-B27), although this accounts for only 20% of the overall genetic risk.
  • More than 40 genes have been implicated in psoriatic disease, including those involved in the innate and adaptive immune response and tissue repair. Specific HLA alleles have been associated with different manifestations of psoriatic disease. People with a first-degree relative with psoriatic arthritis are 40-fold more likely to develop the disease.
  • The HLA-B27 gene has been identified as a risk factor for reactive arthritis.
• Environmental factors:
  
  • Gut microbiome alteration has been associated with spondyloarthritis.
  • Joint or tendon trauma has been implicated in triggering psoriatic arthritis in susceptible people.
  • Infection:
    • Exposure of the immune system to microorganisms from barrier damage to the skin in psoriasis or inflammatory bowel disease may be relevant to the pathogenesis of axial spondyloarthritis.
    • Reactive arthritis is triggered in susceptible people by genitourinary infections with Chlamydia trachomatis or by bacterial enteritis caused by Shigella, Salmonella, Yersinia, and Campylobacter species. HIV infection is also common in people with reactive arthritis.
  • Smoking is associated with the development of psoriasis, although it is unclear whether it also increases the risk of psoriatic arthritis.

[NICE, 2017a; Sieper, 2017; de Koning, 2018; BMJ Best Practice, 2023; Cheeti, 2023; Shahid, 2023]

What are the risk factors?

Risk factors for spondyloarthritis include:

• Chronic inflammatory disease — psoriasis, Crohn's disease, ulcerative colitis, or acute anterior uveitis.
• History of acute anterior uveitis.
• Family history of spondyloarthritis, psoriasis, or psoriatic arthritis.
• Age:
  • Axial spondyloarthritis usually manifests between the ages of 16 and 45 years.
  • The incidence of psoriatic arthritis peaks in the sixth decade in women, but is earlier in men.

[NICE, 2017a; Sieper, 2017; BMJ Best Practice, 2023]

What is the prognosis?

• Axial spondyloarthritis is often characterised by persistent or fluctuating axial inflammation (on MRI) and structural progression (on X-ray).
  • Both the inflammation and new bone formation (if inflammation is ongoing) affect quality of life due to pain and reduction in mobility and function
• Psoriatic arthritis is potentially debilitating, with half of affected people developing irreversible joint damage within 2 years.
  
  • Earlier studies suggested that up to 20% of people experience progressive and disabling symptoms. However, these studies were conducted before the advent of biological therapies and early aggressive treatment. While these interventions can reduce short-term disease activity, it is currently unclear whether this leads to improved long-term outcomes.
• Reactive arthritis is usually self-limiting, with symptoms persisting for 3–5 months. Chronic inflammatory arthritis persists in up to 20% of affected people.

  [Kiltz, 2017; NICE, 2017a; Tucker, 2022; BMJ Best Practice, 2023; Cheeti, 2023]

What are the complications?

• Complications of spondyloarthritis and psoriatic arthropathy include:
  • Progressive, irreversible joint damage.
  • Decreased quality of life, physical function, education and work productivity, and social participation due to pain, stiffness, fatigue, reduced mobility, and sleep problems.
  • Depression and anxiety.
  • Anterior uveitis (iritis).
  • Inflammatory bowel disease.
  • Skin psoriasis.
  • Cardiovascular disease.
    • The risk is thought to be increased in people with spondyloarthritis due to the systemic inflammatory nature of the condition, as well as affected people being less able to maintain good cardiovascular fitness.
    • There may also be common gene loci that predispose to inflammatory illness, as well as cardiovascular risk factors such as type 2 diabetes.
    • Long-term use of NSAIDs may also contribute to this risk.
  • Adverse effects from drugs used to treat the condition, for example, NSAIDs (gastritis, ulcers, and renal effects), biological DMARDs (infection, immunosuppression, and malignancy), and corticosteroids (fractures).
• Axial spondyloarthritis is associated with increased risks of:
  • Osteoporosis.
  • Ankylosis or spinal fusion resulting from new bone formation.
  • Spinal fractures:
    • People with spinal rigidity have a fracture rate of up to 10%, which in some cases is associated with spinal cord injury.
  • Hip and other large joint involvement, which may require joint replacement.

 [Millner, 2016; Taurog, 2016; Kiltz, 2017; McAllister, 2017; NICE, 2017a; Tucker, 2022; BMJ Best Practice, 2023]

When should I suspect spondyloarthritis or psoriatic arthropathy?

See the CKS topics on Psoriasis and Ankylosing spondylitis for detailed advice on the assessment and diagnosis of these conditions.

• Spondyloarthritis should not be ruled in or out by the presence or absence of any individual sign or symptom.
  • Spondyloarthritis may present with diverse symptoms, and as a result, may be difficult to identify.
  • Spondyloarthritis can occur in people who are human leukocyte antigen B27 (HLA‑B27) negative and may be present despite no evidence of sacroiliitis on a plain film X‑ray.
  • Established comorbidities include uveitis, psoriasis, inflammatory bowel disease, and gastrointestinal or genitourinary infection, and there are a number of additional causes and risk factors.
  • Signs and symptoms may be musculoskeletal (for example inflammatory back pain, enthesitis, and dactylitis) and/or extra-articular (for example uveitis and psoriasis; including psoriatic nail symptoms).
• Suspect axial spondyloarthritis in a person with chronic or recurrent low back pain, fatigue, and stiffness, especially if:
  • Onset of pain occurred when the person was 45 years of age or younger.
  • The back pain has been present for more than 3 months.
  • Back pain and stiffness are inflammatory (rather than mechanical) and worse in the morning (lasting for more than 30 minutes), improving with movement.
  • They have current or previous:
    • Buttock pain.
    • Pain in the thoracic or cervical spine.
    • Arthritis, predominately asymmetric and peripheral.
    • Enthesitis (insertional pain at sites of bony attachments to tendons, ligaments, fascia, muscles, or joint capsules).
  • Symptoms wake them in the night (particularly during the second half).
  • Symptoms respond to a course of nonsteroidal anti-inflammatory drugs (NSAIDs) within 48 hours.
  • There is a family history of spondyloarthritis.
  • Other conditions with similar presentations have been excluded. For more information, see the section on Differential diagnosis.
• Suspect psoriatic arthropathy if a person with current or previous psoriasis, or a family history of psoriasis has:
  • Peripheral arthritis — distal interphalangeal joints are commonly affected. Be aware that there may be no correlation between the severity of skin and joint manifestations.
  • Dactylitis — a ‘sausage-like’ swelling of the digit as a result of inflammation of the flexor tendon sheaths of the metacarpophalangeal, metatarsophalangeal, or interphalangeal joints. It is a strong indicator of peripheral spondyloarthritis.
  • Enthesitis.
  • Nail pitting and onycholysis. 
  • The person may report:
    • Monoarticular or oligoarticular involvement.
    • Symmetrical polyarticular involvement.
    • Prolonged morning stiffness lasting more than 30 minutes, improvement with use, and recurrence with rest.
    • Morning first-step foot pain.
    • Lower extremity symptoms that are worse than upper extremity, particularly in the early stages of the disease.
    • Symptoms such as heel pain, elbow pain, or lateral hip pain at bony tendon or ligament attachments (suggestive of enthesitis).
    • Inflammatory back pain.
  • Note: The Psoriasis Epidemiological Screening Tool (PEST) is validated to assess adults with psoriasis for psoriatic arthritis, and is suitable for use in primary care.
  • Be aware that peripheral symptoms in the absence of psoriasis or a family history of psoriasis are potentially suggestive of other spondyloarthritides with peripheral involvement, particularly if the person has inflammatory bowel disease or a recent history of gastrointestinal or genitourinary infection.
• Referral to a rheumatologist is required for confirmation of the diagnosis. For details of the diagnostic criteria used in secondary care, please see the section on Diagnostic criteria in the CKS topic on Ankylosing spondylitis. 
  • Certain investigations can be arranged from primary care prior to referral, in order to expedite the diagnostic pathway, depending on local policies.

How should I assess a person with suspected spondyloarthritis?

To assess a person with suspected spondyloarthritis:

• Ask about the person's symptoms, including:
  • Pain and stiffness and when these are experienced.
  • Whether symptoms are relieved by rest or activity.
  • Extra-articular symptoms such as uveitis
• Enquire about family history of spondyloarthritis, psoriasis, and inflammatory bowel disease.
• Carry out a physical examination where appropriate, and as guided by the person's symptoms, for example, assess affected joints for swelling and impaired mobility.
• For people with features consistent with psoriatic arthritis but no prior history of psoriasis, inspect the skin (particularly the scalp, limbs, and trunk) and nails. For further information on the diagnosis of psoriasis, please see the CKS topic on Psoriasis.
• Consider investigations to support the diagnosis.

What investigations should I consider?

• Spondyloarthritis and psoriatic arthropathy cannot be reliably diagnosed or ruled out by a single test. The following investigations can be considered in primary care, depending on clinical judgement and/or local protocols:
  • Blood tests to rule out potential differential diagnoses, possibly including vitamin D level, uric acid level, serum calcium level, and thyroid function tests.
  • Erythrocyte sedimentation rate (ESR), and/or C-reactive protein (CRP) — these may be elevated in spondyloarthritis, but are normal in many people. Be aware that a diagnosis should not be ruled out if they are normal.
  • HLA-B27 — an HLA-B27 test can be considered in primary care if a person with suspected axial spondyloarthritis has three of the four suggested referral criteria, to help determine whether referral to a rheumatologist is necessary.
  • Rheumatoid factor — can be used where required to help differentiate between psoriatic arthritis (typically negative result) and rheumatoid arthritis (typically positive result).
  • X-rays (note — refer to local protocols. Although X-rays arranged from primary care can speed up the diagnostic pathway, they may be routinely arranged following referral).
    • Plain film X‑ray of the sacroiliac joints and spine for people with suspected axial spondyloarthritis can identify sacroiliitis, sclerosis (thickening of bone), erosions, and partial or total ankylosis (fusion of joints). For more information on spondyloarthritis with radiographic changes, please see the CKS topic on Ankylosing spondylitis. Be aware that spondyloarthritis may be present despite no evidence of sacroiliitis on a plain film X‑ray.
    • Plain film X-rays of the hands and feet in people with suspected psoriatic arthritis can identify erosion in the distal interphalangeal joint and periarticular new bone formation. Soft tissue swelling may be the only radiographic finding in early disease. Plain film X-rays of the pelvis are indicated for all people with suspected psoriatic arthritis as there is a high rate of asymptomatic damage. Plain film X-rays of the spine are indicated in people with features suggestive of sacroiliac, or spine involvement.
  • Ultrasound of the joints of hands and feet and suspected enthesitis sites — can be considered for people with suspected psoriatic arthropathy if a diagnosis cannot be made from a plain film X-ray. Refer to local protocols to determine whether this should be arranged in primary care.
• Do not let investigations delay a referral for clinically suspected spondyloarthritis or psoriatic arthropathy. 

What else could it be?

• Differential diagnoses of axial spondyloarthritis include:
  • Degenerative or mechanical problems (most common) — for example, degenerative disc disease, spondylosis, congenital vertebral anomalies, degenerative changes in the intervertebral (facet) joints, osteoarthritis of sacroiliac joints. For further information, see the CKS topics on Back pain - low (without radiculopathy) and Osteoarthritis.
  • Diffuse idiopathic skeletal hyperostosis (DISH).
  • Fractures — for further information on risk factors, see the CKS topic on Osteoporosis - prevention of fragility fractures.
  • Infectious sacroiliitis.
  • Primary bone tumours or bone metastasis — for further information, see the CKS topic on Bone and soft tissue sarcoma - recognition and referral.
  • Spinal stenosis — for further information, see the CKS topic on Sciatica.
  • Hypermobility.
  • Fibromyalgia — for further information, see the CKS topic on Tiredness/fatigue in adults.
  • Polymyalgia rheumatica — for further information, see the CKS topic on Polymyalgia rheumatica. 
• Other conditions that may cause synovitis include:
  • Rheumatoid arthritis — for further information, see the CKS topic on Rheumatoid arthritis.
  • Gout — for further information, see the CKS topic on Gout.
  • Erosive osteoarthritis — for further information, see the CKS topic on Osteoarthritis.
  • Mycobacterial tenosynovitis — for further information, see the CKS topic on Tuberculosis.
  • Sarcoid dactylitis — for further information, see the CKS topic on Sarcoidosis.
  • Connective tissue disorders — for example, systemic lupus erythematosus (SLE). There may be polyarthritis in the small joints of the hands and feet, but SLE arthritis is usually non-deforming. Suspect this if there are additional signs and symptoms (for example, rash, mouth ulcers, alopecia, Raynaud's syndrome, or Sicca syndrome). 
  • Infectious arthritis (viral or bacterial) — suspect if the person has an ongoing infection. Direct infection of a joint is rare, seek urgent specialist advice if it is suspected.
  • Septic arthritis — suspect if a single joint is hot and swollen, especially if there are signs of sepsis (such as fever).

Scenario: Suspected spondyloarthritis or psoriatic arthropathy

From age 16 years onwards.

Scenario: Confirmed spondyloarthritis or psoriatic arthropathy

From age 16 years onwards.

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Spondyloarthritis and psoriatic arthropathy.

Unrestricted - October 2023

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Spondyloarthritis.tw
• exp Psoiatic arthropathy/, ((psoaitic or psoriasis) adj (arthropathy or arthritis).tw.

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• Health Protection Agency
• World Health Organization
• National Guidelines Clearinghouse
• Guidelines International Network
• TRIP database
• GAIN
• NHS Scotland National Patient Pathways
• New Zealand Guidelines Group
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• Patient UK Guideline links
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work(occupational health practice)

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

• Drug & Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

• Department of Health
• Health Management Information Consortium(HMIC)

• Healthtalkonline
• BMJ - Patient Journeys
• Patient.co.uk - Patient Support Groups

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary(BNF)
• electronic Medicines Compendium(eMC)
• European Medicines Agency(EMEA)
• Medicines and Healthcare products Regulatory Agency(MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

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• Animal studies
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• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

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None.