Classified as a seronegative spondyloarthropathy. The seronegative spondyloarthropathies (including psoriatic arthritis, enteropathic arthritis, and reactive arthritis) are a heterogenous group of conditions with overlapping clinical manifestations and association with the gene HLA-B27.
Predominantly affects the sacroiliac joints and axial spine.
Inflammatory back pain is the hallmark clinical feature. This is defined as back pain that is of insidious onset, is worse in the morning, and improves with exercise.
A positive response to nonsteroidal anti-inflammatory drugs (NSAIDs) is characteristic of most patients.
Physical therapy and NSAIDs are the cornerstone of treatment. In people whose symptoms are refractory to these approaches, tumor necrosis factor (TNF)-alpha inhibitors and interleukin-17 inhibitors play a key role.
Axial spondyloarthritis (AxSpa) is a chronic progressive inflammatory arthropathy. Patients present with severe pain and spinal stiffness, which ultimately may lead to radiographic changes in the spine and sacroiliac joints. This radiographic stage is known as ankylosing spondylitis (AS). Progression of disease may lead to spinal fusion. Patients with complete spinal fusion suffer extreme disability.
Nonradiographic axial spondyloarthritis (nr-axSpA) describes axial inflammation visible on magnetic resonance imaging (MRI) that has not caused substantial erosive damage to the sacroiliac joints. Patients can be classified as nr-axSpA on the basis of a positive MRI of the sacroiliac joint.
History and exam
Antoni Chan, MBChB, FRCP, PhD
Royal Berkshire NHS Foundation Trust
AC has served on the advisory boards for MSD, Novartis, and Sanofi; contributed to educational events for Janssen, MSD, Novartis, Sanofi, and Celgene; been on the speaker bureau for Janssen, Pfizer, and Novartis; and received travel grants from AbbVie, UCB, Lilly, and Pfizer to attend educational conferences.
Sarah Sacks, MBBS, BSc
Specialist Registrar in Rheumatology
Stoke Mandeville Hospital
SS declares that she has no competing interests.
Dr Antoni Chan and Dr Sarah Sacks would like to gratefully acknowledge Dr Jessica Gunn, Dr Sarah Keidel, Dr Millicent Stone, Dr Raj Sengupta, Dr Athimalaipet V. Ramanan, and Dr Emma Pomeroy, the previous contributors to this topic.
JG, SK, RS, and AVR declare that they have no competing interests. MS is an author of several references cited in this topic. EP is an author of a reference cited in this topic.
Roger Sturrock, MD, FRCP
Professor of Rheumatology
Centre for Rheumatic Diseases
University Department of Medicine
Glasgow Royal Infirmary University Trust
RS is an author of a reference cited in this topic.
Andrew Keat, MBBS
Consultant Physician and Rheumatologist
Northwick Park Hospital
AK declares that he has no competing interests.
Karl Gaffney, BCh, BAO (Hons), FRCPI, FRCP
Norfolk and Norwich University Hospital
Norwich and the Cromer & District Hospital
KG is an author of a reference cited in this topic.
Alexios G. Carayannopoulos, DO, MPH
Interventional Spine Physiatrist
Pain Medicine Specialist
AGC declares that he has no competing interests.
2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis external link opens in a new windowMore guidelines
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