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Musculoskeletal

Spondyloarthropathies

A family of inflammatory arthritides with axial or peripheral patterns, enthesitis, dactylitis and characteristic extra-articular disease involving the eye, skin and gut.

In a nutshell

Spondyloarthritis is a clinical family of axial and peripheral inflammatory disease with enthesitis, dactylitis and possible uveitis, psoriasis or inflammatory bowel disease. HLA-B27 and inflammatory markers support but do not rule in or rule out the diagnosis.

Classic presentation

Inflammatory back pain improving with movement, or asymmetric lower-limb arthritis with enthesitis, dactylitis, psoriasis, inflammatory bowel disease or acute anterior uveitis.

Key points

  • Inflammatory back pain improves with movement and is worse with rest or at night.
  • Negative HLA-B27, normal CRP or normal ESR does not exclude spondyloarthritis.
  • Use sacroiliac X-ray first when appropriate, followed by inflammatory-protocol MRI if X-ray is negative or unsuitable.
  • NSAID plus structured exercise is the usual axial starting point; conventional DMARDs are for persistent peripheral disease.
  • Active axial disease that remains uncontrolled needs specialist biologic or targeted therapy assessment.
  • A painful red eye with photophobia or blurred vision is same-day ophthalmology territory.
  • A hot acutely swollen joint needs urgent exclusion of septic arthritis or crystals.

First-line investigation

Clinical inflammatory-pattern assessment with CRP/ESR and HLA-B27 as supportive tests, sacroiliac imaging for axial disease, and joint aspiration when an acute hot joint requires exclusion of infection or crystals.

Management

Recognise and refer

  • Use the inflammatory pattern and associated disease to refer to rheumatology; do not dismiss the diagnosis because HLA-B27, CRP or ESR is negative or normal.1

Treat axial symptoms and preserve function

  • Start structured exercise and physiotherapy with an NSAID at the lowest effective dose, monitoring gastrointestinal, renal and cardiovascular risk and using gastroprotection where indicated.1,5

Treat peripheral disease

  • Use local corticosteroid treatment selectively and conventional DMARDs for persistent peripheral arthritis under specialist care; do not use them as a substitute for axial advanced therapy.1,5

Escalate active axial disease

  • Use NICE technology appraisals and the current BSR axial guideline to select and monitor biologic or targeted synthetic DMARD therapy when active disease remains uncontrolled.1,6,5

Protect eyes, organs and spine

  • Coordinate uveitis, psoriasis and bowel care, monitor cardiovascular and bone health, and assess new severe spinal pain after trauma urgently for fracture.1,3

Exam traps

  • HLA-B27 is not a rule-in or rule-out test.
  • Normal inflammatory markers do not exclude axial spondyloarthritis.
  • Conventional DMARDs help peripheral arthritis but are not the treatment for isolated axial inflammation.
  • Acute anterior uveitis needs same-day eye assessment.
  • A presumed inflammatory flare must not delay aspiration of a hot joint when septic arthritis is possible.

Illustrations

Achilles enthesitis in psoriatic arthritis on MRISagittal ankle MRI sequences from psoriatic arthritis showing inflammatory change at the Achilles tendon insertion, illustrating enthesitis as a hallmark of spondyloarthropathy.Fiona McQueen, Marissa Lassere and Mikkel Østergaard, Wikimedia Commons · CC-BY-2.0

Key sources

  1. NICE NG65: Spondyloarthritis in over 16s: diagnosis and management (UK referral, imaging, exercise, NSAID, peripheral treatment, biologic eligibility and complication guidance; reviewed March 2025.)Updated 4 Mar 2025
  2. NHS: Ankylosing spondylitis (UK information on axial disease, exercise, anti-inflammatory treatment and advanced therapies.)
  3. NICE CG153: Psoriasis: assessment and management (UK screening and rheumatology referral pathway for psoriatic arthritis and coordinated psoriasis care.)
  4. NHS: Reactive arthritis (UK information on clinical features, urgent red flags, testing, treatment and prognosis for reactive arthritis.)Updated 16 Dec 2024
  5. BNF online (Check current NSAID, DMARD, biologic and targeted therapy prescribing, interactions, contraindications and monitoring.)
  6. British Society for Rheumatology: 2025 guideline for axial spondyloarthritis with biologic and targeted synthetic DMARDs (Current UK specialist guidance for advanced therapy selection and monitoring in axial spondyloarthritis.)Updated 9 Apr 2025

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.