Chronic inflammatory back pain (IBP) is one of the characteristic features of axial spondyloarthritis (axSpA), but it is not the only thing that frontline healthcare professionals need to be attentive to when treating someone with this rheumatic condition.
As axSpA can affect not only the sacroiliac and vertebral joints but also peripheral joints in the hands, wrists, elbows, shoulders, knees, ankles, and feet, people may suffer from a variety of joint and tendon pain. There are also strong connections to other inflammatory conditions that may be present even in the absence of IBP.
Extra-Articular Manifestations (EAMs) of AxSpA
„It is important to remember that spondyloarthritis is not just about back pain,“ said physiotherapist Heather Harrison. Harrison works with a rheumatology consultant at an IBP clinic in England and is a member of AStretch, an English nonprofit organization that provides education and support to physiotherapists helping people with axSpA.
Enthesitis, plantar fasciitis, and Achilles tendonitis are just three of the non-spinal issues that can occur in people with axSpA, but there are also „associated conditions“ such as acute anterior uveitis, psoriasis, and inflammatory bowel disease (IBD).
These EAMs contribute to the morbidity of axSpA and „can lead to a restriction in the quality of life of patients,“ said Harrison.
„Questioning patients about the symptoms of these comorbid conditions can be helpful in early diagnosis and optimal treatment,“ so being aware of these associated conditions is very important, she added.
How likely are you to see extra-articular features of AxSpA in primary care?
Published estimates of the prevalence of the major EAMs in people with axSpA and ankylosing spondylitis vary, but they tend to be in the same range – about 20–30% for acute anterior uveitis, 5–10% for psoriasis, and 5–10% for IBD, including Crohn’s disease and ulcerative colitis.
However, the actual prevalence of these conditions might be much higher, as studies suggest, for example, that subclinical bowel inflammation may be present in 25–49% of patients with axSpA.
As with axSpA itself, the presence of the human leukocyte antigen (HLA)-B27 allele of the major histocompatibility complex-1 is strongly associated with the presence of an EAM of the disease, although they can still occur in patients who are HLA-B27 negative.
While it is important to be vigilant for EAMs in people already diagnosed with axSpA, it is also important to be aware of undiagnosed axSpA in patients with any of the known EAMs.
In a recent review, authored by axSpA experts Karl Gaffney, MBBCh, from the Norfolk and Norwich University Hospitals NHS Foundation Trust, and Raj Sengupta, MBBS, from the Royal National Hospital for Rheumatic Diseases in Bath, England, it is noted that up to 78% of patients with anterior uveitis, 24% of patients with psoriatic arthritis, and 40% of patients with IBD might actually have axSpA.
How to recognize and manage them?
How patients with axSpA-EAMs are identified and treated really depends on what the patient’s main complaint is and where they are referred to, said Harrison. If a patient is suffering from acute anterior uveitis, a very painful eye condition, they will not be treated in primary care but will need to go directly to the emergency department to see an ophthalmologist. Symptoms include severe eye pain and redness, sensitivity to light, and reduced visual acuity. There is also a tendency for this to recur, she noted.
People with predominantly intestinal or skin problems may be treated in primary care for a short period but are highly likely to be referred to a gastroenterologist or dermatologist. Symptoms of IBD may include abdominal pain, diarrhea, weight loss, and blood loss, and there may be a family history. Psoriasis presents with red and scaly skin, which can cause itching and pain. The condition may also run in the family.
And of course, those with chronic suspicion of IBP and other characteristic features of axSpA (e.g. age < 45 years, insidious onset, improvement with physical activity but not at rest, and night pain) should be referred to a rheumatologist as soon as possible.
Difficult treatment decisions
Treating axSpA-EAMs can be difficult as what works for one issue may not always work for another. While nonsteroidal anti-inflammatory drugs can be used to treat inflammation in axSpA before a patient receives a biologic, these may be problematic for people with IBD as they can exacerbate the intestinal disease. Disease-modifying anti-rheumatic drugs like methotrexate and corticosteroids are commonly used to treat patients with IBD, but these are generally not effective in treating IBP.
„It’s kind of a negotiation between specialties,“ said Harrison.
A good example is the type of biological therapy. The goal would be to use a biologic that is suitable for both intestinal and joint symptoms or for skin and joint symptoms, which typically means using a tumor necrosis factor agent. But this is a multidisciplinary decision and is usually made in secondary care.
Good communication and referrals
Good communication and referrals between specialties are therefore crucial to ensure that the best treatment is provided, said Harrison.
„We obviously have patients referred to us from gastroenterology,“ she said, „and then there are also patients that we treat in our clinic with intestinal issues and then refer to gastroenterology.“ The same goes for skin issues, she noted.
Harrison has been involved in educating nurses and other related professionals in other specialties about the symptoms of axSpA, „so hopefully they can identify patients in their clinics.“
„At the very least, think about checking the skin, eyes, intestines, and extremities,“ advised Harrison.