Clin Rheumatol (2015) 34:987–993 DOI 10.1007/s10067-015-2958-2
ORIGINAL ARTICLE
Screening and referral for axial spondyloarthritis—need of the hour Abhijeet Danve 1 & Atul Deodhar 2
Received: 7 March 2015 / Accepted: 12 April 2015 / Published online: 7 May 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract Although axial spondyloarthritis (axSpA) is as prevalent as rheumatoid arthritis, it is commonly under recognized due to variety of reasons. AxSpA contributes to significant loss of function and disability among young adults. With the availability of newer assessment methods and effective therapeutic agents, early diagnosis and appropriate treatment are possible. As mechanical back pain is widely prevalent in general population, selection of patients with high likelihood of having axSpA and referral to rheumatologists is very important to allow prompt diagnosis and management of axSpA yet avoid improper utilization of resources. Various referral strategies have been developed for this purpose which have included patients with chronic back pain for >3 months with age of onset 95 % of patients are symptomatic by age 45 years
Clin Rheumatol (2015) 34:987–993
989
[7]. Most of the referral strategies use Bage at the onset of symptoms 3 months^ as an entry criterion as the target population. Traditionally, AS has been considered to be a disease predominantly seen in men, but the male to female ratio has slowly moved toward parity (M/F ratio 2:1) [33, 34]. With the recognition of non-radiographic axial spondyloarthritis (nr-axSpA), it is known that women develop nr-axSpA with the same frequency as men, but they less commonly progress to radiographic disease [35, 36]. Therefore we feel it is important to educate the referring providers regarding women being equally at risk as men in developing axSpA so that both men and women with chronic back pain will be appropriately screened. First-degree relatives of patients with AS have 5.6- to 16fold higher risk of developing AS. About 10 to 20 % of HLAB27-positive individuals with affected first-degree relatives develop AS. Therefore, this can also be a target population for screening for axSpA [37]. Patients with acute anterior uveitis and inflammatory bowel disease have a much higher risk of developing axSpA compared to general population (likelihood ratio 7.3 and 4.0, respectively) [38]. Therefore, patients with these diseases could be potential candidates for screening for presence of axSpA in ophthalmology and gastroenterology clinics. Also, patients with psoriasis have a 30 % chance of developing psoriatic arthritis, and a large percentage of these are at an increased risk of developing axSpA [39].
part of the referral strategy in all the studies (see Table 1). Ever since Calin et al. introduced the criteria for inflammatory back pain in 1977 (4/5 variables required sensitivity 95 %, specificity 85 %), many other sets of criteria have been developed, e.g., Berlin criteria in 2008 (2 of 4 required, sensitivity 70 %, specificity 81 %) and ASAS criteria in 2009 (4 of 5 required, sensitivity 80 %, specificity 72 %). The sensitivity and the specificity of these criteria have been very similar. Most of the referral strategies have kept the definition of inflammatory back pain (IBP) less stringent and allowed referring physician to use his or her judgment. It is important to remember that IBP also can be present in 20 to 25 % of the patients with mechanical back pain [38], and hence, it may not be the best single criterion for screening. Other candidate parameters commonly used in the referral strategies have included evidence of sacroiliitis on available imaging (X-ray or MRI), presence of HLA-B27, family history of AS or axSpA, good response to NSAIDs, and extra-articular manifestations of SpA (psoriasis, inflammatory bowel disease, and uveitis). Enthesitis, dactylitis, and inflammatory arthritis have high specificity but low sensitivity and, hence, may not be very useful for screening. Acute phase reactants, mainly C-reactive protein (CRP), have pooled estimated sensitivity and specificity of 50 and 80 %, respectively, but due to its low sensitivity, it has not been included in any strategies till now. However CRP, a relatively inexpensive measure, remains a well-recognized parameter used to assess the disease activity and has prognostic value.
Who are the potential referring providers?
Screening and referral studies for axSpA
According to a multinational survey of rheumatologists, primary care physicians and physical therapists are the commonest referral sources for majority of axSpA patients seen in rheumatology clinics in the USA [40]. Other sources of referral are orthopedic surgeons, spine surgeons, chiropractors, pain specialists, and rehabilitation specialists. Dermatologists, ophthalmologists, and gastroenterologists are also potential sources of referral. It is important to educate these providers about the prevalence of axSpA and provide them with the tools to identify this condition in order to facilitate early referral.
Prospective Study of Spondyloarthritis (ProSpA) was a recent multicenter study conducted in the USA [41]. Patients with chronic low back pain for more than 3 months with onset before the age of 45 years and with more than one of the following SpA features were referred to rheumatologists: (1) positive HLA-B27, (2) current IBP, or (3) MRI/X-ray evidence of sacroiliitis. These patients were referred from primary care physicians (PCP) or self-referred, or were existing patients at the investigative site. Of the 751 patients, 319 (46 %) were diagnosed by the investigator as having axSpA. The referral strategy employed in this study yielded a nearly 50:50 chance of identifying axSpA patients. There have been several single-center [23, 24, 28], multicenter [26], and international [27] studies evaluating strategies for screening and referral of axSpA (see Table 1). Overall prevalence of axSpA in these studies ranged from 33 to 46 % irrespective of the screening strategy used. The referral strategies have included either entry criterion (back pain onset before the age of 45 years, duration more than 3 months) only [28]; entry criterion plus IBP only [24, 25]; or entry criteria plus combination of clinical, laboratory, and
Which clinical tools can be used to screen and refer patients with suspected axSpA? To identify patients with axSpA from the larger pool of chronic back pain patients, it is important to include spondyloarthritis (SpA) clinical features with high sensitivity and reasonable specificity in the assessment of young adults with chronic back pain. Since inflammatory back pain is considered to be the hallmark of the axSpA, it has been an integral
GP
Ortho
GP and ortho
Hermann (2009)
Braun (2011)
Poddubnyy 2011 MASTER study Strategy 1, ≥1 of IBP, + HLA-B27, sacroiliitis on available imaging Strategy 2, 2 of 5 IBP, + HLA-B27, sacroiliitis on available imaging, positive family history for AS, good response to NSAID LBP >3 m, onset 2 m
ORIGINAL ARTICLE
Screening and referral for axial spondyloarthritis—need of the hour Abhijeet Danve 1 & Atul Deodhar 2
Received: 7 March 2015 / Accepted: 12 April 2015 / Published online: 7 May 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract Although axial spondyloarthritis (axSpA) is as prevalent as rheumatoid arthritis, it is commonly under recognized due to variety of reasons. AxSpA contributes to significant loss of function and disability among young adults. With the availability of newer assessment methods and effective therapeutic agents, early diagnosis and appropriate treatment are possible. As mechanical back pain is widely prevalent in general population, selection of patients with high likelihood of having axSpA and referral to rheumatologists is very important to allow prompt diagnosis and management of axSpA yet avoid improper utilization of resources. Various referral strategies have been developed for this purpose which have included patients with chronic back pain for >3 months with age of onset 95 % of patients are symptomatic by age 45 years
Clin Rheumatol (2015) 34:987–993
989
[7]. Most of the referral strategies use Bage at the onset of symptoms 3 months^ as an entry criterion as the target population. Traditionally, AS has been considered to be a disease predominantly seen in men, but the male to female ratio has slowly moved toward parity (M/F ratio 2:1) [33, 34]. With the recognition of non-radiographic axial spondyloarthritis (nr-axSpA), it is known that women develop nr-axSpA with the same frequency as men, but they less commonly progress to radiographic disease [35, 36]. Therefore we feel it is important to educate the referring providers regarding women being equally at risk as men in developing axSpA so that both men and women with chronic back pain will be appropriately screened. First-degree relatives of patients with AS have 5.6- to 16fold higher risk of developing AS. About 10 to 20 % of HLAB27-positive individuals with affected first-degree relatives develop AS. Therefore, this can also be a target population for screening for axSpA [37]. Patients with acute anterior uveitis and inflammatory bowel disease have a much higher risk of developing axSpA compared to general population (likelihood ratio 7.3 and 4.0, respectively) [38]. Therefore, patients with these diseases could be potential candidates for screening for presence of axSpA in ophthalmology and gastroenterology clinics. Also, patients with psoriasis have a 30 % chance of developing psoriatic arthritis, and a large percentage of these are at an increased risk of developing axSpA [39].
part of the referral strategy in all the studies (see Table 1). Ever since Calin et al. introduced the criteria for inflammatory back pain in 1977 (4/5 variables required sensitivity 95 %, specificity 85 %), many other sets of criteria have been developed, e.g., Berlin criteria in 2008 (2 of 4 required, sensitivity 70 %, specificity 81 %) and ASAS criteria in 2009 (4 of 5 required, sensitivity 80 %, specificity 72 %). The sensitivity and the specificity of these criteria have been very similar. Most of the referral strategies have kept the definition of inflammatory back pain (IBP) less stringent and allowed referring physician to use his or her judgment. It is important to remember that IBP also can be present in 20 to 25 % of the patients with mechanical back pain [38], and hence, it may not be the best single criterion for screening. Other candidate parameters commonly used in the referral strategies have included evidence of sacroiliitis on available imaging (X-ray or MRI), presence of HLA-B27, family history of AS or axSpA, good response to NSAIDs, and extra-articular manifestations of SpA (psoriasis, inflammatory bowel disease, and uveitis). Enthesitis, dactylitis, and inflammatory arthritis have high specificity but low sensitivity and, hence, may not be very useful for screening. Acute phase reactants, mainly C-reactive protein (CRP), have pooled estimated sensitivity and specificity of 50 and 80 %, respectively, but due to its low sensitivity, it has not been included in any strategies till now. However CRP, a relatively inexpensive measure, remains a well-recognized parameter used to assess the disease activity and has prognostic value.
Who are the potential referring providers?
Screening and referral studies for axSpA
According to a multinational survey of rheumatologists, primary care physicians and physical therapists are the commonest referral sources for majority of axSpA patients seen in rheumatology clinics in the USA [40]. Other sources of referral are orthopedic surgeons, spine surgeons, chiropractors, pain specialists, and rehabilitation specialists. Dermatologists, ophthalmologists, and gastroenterologists are also potential sources of referral. It is important to educate these providers about the prevalence of axSpA and provide them with the tools to identify this condition in order to facilitate early referral.
Prospective Study of Spondyloarthritis (ProSpA) was a recent multicenter study conducted in the USA [41]. Patients with chronic low back pain for more than 3 months with onset before the age of 45 years and with more than one of the following SpA features were referred to rheumatologists: (1) positive HLA-B27, (2) current IBP, or (3) MRI/X-ray evidence of sacroiliitis. These patients were referred from primary care physicians (PCP) or self-referred, or were existing patients at the investigative site. Of the 751 patients, 319 (46 %) were diagnosed by the investigator as having axSpA. The referral strategy employed in this study yielded a nearly 50:50 chance of identifying axSpA patients. There have been several single-center [23, 24, 28], multicenter [26], and international [27] studies evaluating strategies for screening and referral of axSpA (see Table 1). Overall prevalence of axSpA in these studies ranged from 33 to 46 % irrespective of the screening strategy used. The referral strategies have included either entry criterion (back pain onset before the age of 45 years, duration more than 3 months) only [28]; entry criterion plus IBP only [24, 25]; or entry criteria plus combination of clinical, laboratory, and
Which clinical tools can be used to screen and refer patients with suspected axSpA? To identify patients with axSpA from the larger pool of chronic back pain patients, it is important to include spondyloarthritis (SpA) clinical features with high sensitivity and reasonable specificity in the assessment of young adults with chronic back pain. Since inflammatory back pain is considered to be the hallmark of the axSpA, it has been an integral
GP
Ortho
GP and ortho
Hermann (2009)
Braun (2011)
Poddubnyy 2011 MASTER study Strategy 1, ≥1 of IBP, + HLA-B27, sacroiliitis on available imaging Strategy 2, 2 of 5 IBP, + HLA-B27, sacroiliitis on available imaging, positive family history for AS, good response to NSAID LBP >3 m, onset 2 m
