These parameters comprise:
- IBP;
- Enthesitis;
- Peripheral arthritis;
- Dacylitis;
- Acute anterior uveitis (AAU);
- Family history of AS, AAU, inflammatory bowel disease (IBD), or reactive arthritis (ReA);
- Psoriasis;
- IBD;
- Good response to nonsteroidal antiinflammatory drugs (NSAIDs);
- Elevated acute phase reactants;
- Presence of HLA-B27; and
- MRI evidence of sacroiliitis.4
Dr. Khan narrowed the predominate factors down to four, based on the sensitivity and specificity data compiled by Rudwaleit et al to create the above list: “If a patient has IBP, acute anterior uveitis, a family history of these diseases, and a good response of IBP to NSAIDs, you should strongly suspect that the patient has SpA.”
He also stressed the need for good history taking when a patient has back pain. “The physician has not even touched the patient; yet there is already a high likelihood that the patient has axial spondylarthritis,” said Dr. Khan.
New ASAS Classification Criteria
There are two sets, or arms, of the ASAS criteria: the imaging arm and the clinical arm.5 Each set is applied to patients with chronic (more than three months) back pain, the onset of which occurs at less than 45 years of age.
The imaging arm requires only one clinical parameter plus sacroiliitis (X-rays or MRI):
- The sacroiliitis should show definite radiographic disease at grade 2 bilateral or grade 3 to 4 unilateral (according to modified NY criteria 1984); or
- There should be active (acute) inflammation of sacroiliac joints on MRI, highly suggestive of sacroilliitis associated with SpA.
The clinical arm requires a positive HLA-B27 test plus two other clinical parameters, such as:
- IBP;
- Arthritis;
- Enthesitis;
- Uveitis;
- Psoriasis;
- Crohn’s disease/ulcerative colitis;
- Good response to NSAIDs;
- Family history of SpA;
- Elevated C-reactive protein; and
- Presence of HLA-B27.
Management of Axial Spondylarthritis
The first step in managing SpA, said Dr. Kahn, is a three-point approach: patient education, NSAIDs, and physical therapy combined with the development of a lifelong exercise program.
Educating the patient about his or her condition and about actively participating in treatment is crucial. Dr. Khan emphasized that “the word doctor does not mean healer; it means educator. If you don’t educate the patient, you cannot expect compliance” to treatment. The clinician should also encourage the patient to join self-help groups.
NSAIDs decrease spinal and peripheral joint pain and improve function. Prescribing an NSAID that is taken once or twice a day improves compliance. In patients with increased gastrointestinal risk, a gastroprotective agent can be added, or the patient can switch to selective COX-2 inhibitors (coxibs) because they are equally effective.
