NASS has sucessfully campaigned for NICE to produce guidelines on spondyloarthritis
Debbie Cook, Chief Executive at NASS has been a member of the Guideline Development Group working with NICE for over two years, particularly giving the patients’ perspective.
The Guideline was issued at the end of February 2017.
NASS will be working hard to promote the guideline and to ensure the recommendations contained within them are taken on board. We welcome this guideline and we’ll keep you informed of the impact it has on diagnosis and care.
We have summarised what the guideline says for people with AS. You can read it in full on the NICE website.
The guideline advises GPs not to rule out the possibility of spondyloarthritis solely on the presence or absence of any individual sign, symptom or test result. GPs are reminded spondyloarthritis can have diverse symptoms and be difficult to identify, which can lead to delayed or missed diagnoses. They are particularly reminded:
- AS affects women and men equally
- AS can occur in people who are HLA B27 negative
- AS can be present despite no evidence of sacroiliitis on x-ray
GPs are advised to refer people with low back pain, that started at under 45 years of age and has lasted for longer than 3 months, to a rheumatologist for a spondyloarthritis assessment when at least 4 of the following are present:
- Back pain started at under 35 years
- Waking during the second half of the night
- Buttock pain
- Pain and stiffness improves with movement
- Improvement within 48 hours of taking anti inflammatories
- A first-degree relative with spondyloarthritis (e.g. Father or Mother)
- Current or past arthritis, enthesitis or psoriasis
Rheumatologists are recommended to first use x-ray and, if AS is not diagnosed by x-ray, to carry out full spine STIR sequence MRI. It’s recommended that if the MRI does not show signs of AS but clinical suspicion remains high, a follow-up MRI should be considered.
Information and Support
NICE advise people are provided with information that is:
- Available on an ongoing basis
- Relevant to the stage of the person’s condition
- Tailored to the person’s needs
They specifically recommend people are advised about flares and are given a tailored flare management plan. A management plan should include:
- How to access care during a flares
- How to self-care (for example, exercises, stretching and joint protection)
- Information on pain and fatigue management
- Information on medicines
- How to manage the impact on daily life and ability to work.
NICE also suggest information should be provided on uveitis, psoriasis and inflammatory bowel disease.
NICE recommend anti inflammatories are offered for pain associated with AS and if an anti inflammatory taken at the maximum tolerated dose for 2 to 4 weeks does not provide adequate pain relief, the rheumatologist or GP should consider switching to another anti inflammatory. Biologics including anti TNF and anti IL 17A should be offered in line with current NICE guidance.
NICE recommend flares are managed by either the GP or rheumatologist depending on the persons’ needs. They highlight that GPs should seek specialist advice if needed, especially where people:
- Have recurrent or persistent flares
- Are taking biologic medications like anti TNF or anti IL17A
- Have other medical conditions that may affect the treatment or management of flares
People should only be referred to a complex spinal surgery service to be assessed for spinal deformity correction if the spinal deformity is significantly affecting their quality of life and is severe or progressing.
Credit: BMJ 2017;356:j839