This is a new guideline from NICE and covers conditions like ankylosing spondylitis, psoriatic arthritis and reactive arthritis. It applies to over 16s only. A lot of this is not new, so I am going to summarise the new or interesting points.

Pitfalls in recognition:

  • Don't rule it out because of the absence or presence of any one symptom or sign or test result.
  • Affects as many women as men.
  • Can be HLA-B27 negative.
  • May be no sacroiliitis on xray.


  • Inflammatory type back pain.
  • Enthesitis (swelling at tendon insertions).
  • Dactylitis (swelling of whole fingers or toes).
  • Extra-articular features (eg uveitis, psoriasis).


Low back pain that started before age 45 AND

Lasted for 3m or more AND

4 or more of the following are present (or 3 or more and are HLA-B27 positive):

  • Low back pain started before age 35
  • Waking in second half of the night with back pain
  • Buttock pain
  • Improves with movement
  • Improves within 48 hrs of NSAID use
  • 1st degree relative with spondyloarthritis
  • Current or past arthritis, enthesitis or psoriasis

If the patient doesn't meet the above criteria, but there is still concern, advise the patient that they should re-present if there are new features or risk factors.

Referral with specific conditions

Psoriatic arthritis

See the NICE guideline

Rheumatoid arthritis

See the NICE guideline.


Refer to rheumatology.


If there is no obvious mechanical cause - refer to rheumatology if:

  • 1st degree relative has spondyloarthritis or psoriasis OR
  • Multiple sites OR
  • Persistent OR
  • Any of the following are also present:
    • Back pain with no obvious mechanical cause
    • Current or past uveitis
    • Current or past psoriasis
    • GI or GU infection
    • IBD

Anterior Uveitis

This is aimed at opthalmology, but may be relevant to us too. If a patient presents with anterior uveitis, ask if:

  • Patient has previously presented to the GP with joint pains.
  • Patient has had back pain that started before age 45 and lasted more than 3m.

If either of the above are true, then the patient should be referred to rheumatology IF

  • They have psoriasis OR
  • Don't have psoriasis, but are HLA-B27 positive.

Long term complications

  • Consider risk factors for CVD.
  • Possible increased risk of skin CA with TNFa inhibitors.
  • Osteoporosis - need assessing every 2 years.

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