Early Recognition of Patients with Axial Spondyloarthritis by Using a Practical Referral System – Evaluation of the Recently Proposed 2-step Strategy

Xenofon Baraliakos¹, Styliani Tsiami ², doris morzeck ², Kirill Fedorov ², Uta Kiltz ² and Jürgen Braun ³, ¹Rheumazentrum Ruhrgebiet-Ruhr-University Bochum, Herne, Germany, Herne, Germany, ²Rheumazentrum Ruhrgebiet/Ruhr University Bochum, Herne, Germany, Herne, Germany, ³Rheumazentrum Ruhrgebiet/Ruhr University, Herne, Germany

Meeting: 2019 ACR/ARP Annual Meeting

Keywords: axial spondyloarthritis and back pain

Session Information

Date: Sunday, November 10, 2019

Title: Spondyloarthritis Including Psoriatic Arthritis – Clinical Poster I: Axial Spondyloarthritis, Clinical Features

Session Type: Poster Session (Sunday)

Session Time: 9:00AM-11:00AM

Background/Purpose: Early recognition of axial spondyloarthritis (axSpA) in primary care (PC) is difficult due to the high prevalence of low back pain resulting in a major delay for a diagnosis of axSpA. Recently we proposed a 2-step referral strategy (1) which concentrates on patients ≤45 years with chronic back pain who are to be referred to a rheumatologist if fulfilling 2 of 3 features: buttock pain, improvement by movement, psoriasis (Step 1), or, in case of ≤1 feature, positive testing for HLA-B27 (Step 2). We prospectively evaluated this 2-step referral strategy in PC.

Methods: Consecutive patients ≤45 years who presented in PC to general practitioners or orthopedic surgeons working in PC with back pain lasting ≥2 months who had not been diagnosed before received questionnaires (Q1) relevant for the referral process. Thereafter, the PC physician asked the same questions in a separate questionnaire (Q2), including the decision on HLA-B27 testing. All patients were then referred to two experienced rheumatologists in a tertiary center who performed a complete workup including clinical, laboratory and imaging with radiographs and magnetic resonance imaging (MRI) examinations before their final diagnosis of axSpA or non-SpA (Q3).

Results: A total of 320 patients (mean age 35.9±10.3 years) was recruited. The proposed referral strategy (prS) was fulfilled by 127 patients in Q1 (39.7%), 160 in Q2 (50%), 102 by both, Q1 and Q2 (31.9%), and 83 with either Q1 or Q2 (25.9%). Overall, 47 patients were diagnosed with axSpA by the rheumatologist at Q3 (14.7%), 66% of which were male, mean age 34.7±10.1 years, 70.2% HLA-B27 positive, mean CRP 0.8±1.4mg/dl, mean ASDAS 3.2±0.8, mean BASDAI 5.1±2.0. Of these, 37 patients had fulfilled the prS in Q1 or Q2 (78.7%), and 31 in both Q1 and Q2 (66%), respectively. In the latter, the HLA-B27 prevalence was significantly higher (27/31, 87.1%) as compared to patients diagnosed with axSpA at Q3 but who did not fulfill the prS in Q1 and Q2 (5/16, 31.3%) (p< 0.001). The sensitivity and specificity of the prS was 78.7% and 69.2% in Q1, 78.7% and 62.2% in Q2, and in both, Q1 and Q2, 66% and 74%, respectively. AxSpA patients correctly identified by the prS in Q1 and Q2, were significantly more frequently positive for HLA-B27 and CRP and fulfilled more frequently the ASAS definition of inflammatory back pain in Q3.

Conclusion: A simple two-step referral strategy using a combination of clinical features for identifying axSpA patients in PC without laboratory and imaging examinations was confirmed in a large population from daily practice. This strategy performed well as selection for referral at the patient and PC physician level.

Braun A et al, ARD 2011

Disclosure: X. Baraliakos, AbbVie, 2, 5, 8, Abbvie, 2, 5, 8, BMS, 2, 5, 8, 9, Bristol-Myers Squibb, 2, 5, 8, Celgene, 2, 5, 8, 9, Chugai, 2, 5, 8, 9, Janssen, 2, 5, 8, 9, Lilly, 2, 8, 9, Merck, 2, 5, 8, MSD, 2, 5, 8, 9, Novartis, 2, 5, 8, 9, Novatis, 2, 5, 8, Pfizer, 2, 5, 8, 9, UCB, 2, 5, 8, 9, UCB Pharma, 2, 5, 8, Werfen, 2, 5, 8; S. Tsiami, None; d. morzeck, None; K. Fedorov, None; U. Kiltz, AbbVie, 2, 5, 8, ABBVIE, NOVARTIS, CHUGAI, JANSEN, MSD, UCB, 8, ABBVIE, NOVARTIS, LILLY,BIOCAD, GRUNENTHAL,UCB, 5, ABBVIE, NOVARTIS, PFIZER,BIOGEN, 2, Biocad, 2, 5, Biogen, 2, 5, Chugai, 2, 5, 8, Eli Lilly, 2, 5, Eli Lilly and Company, 5, Grünenthal, 2, 5, 8, Janssen, 8, Jasnssen, 2, 5, MSD, 2, 5, 8, Novartis, 2, 5, 8, Pfizer, 2, 5, Roche, 2, 5, 8, UCB, 2, 5, 8; J. Braun, Abbott, 2, 5, AbbVie, 2, 5, 6, 8, Amgen, 2, 5, 8, Baxter, 2, 5, 8, Biogen, 2, 8, 9, BMS, 2, 5, 8, Boehringer, 2, 5, 8, Bristol-Myers Squibb, 2, 5, Celgene, 2, 3, 5, 8, Celltrion, 2, 5, 8, Centocor, 2, 5, 8, Chugai, 2, 5, 8, Eli Lilly and Company, 2, 5, 8, Hexal, 2, 5, 8, Janssen, 2, 5, 8, Johnson & Johnson, 2, 5, Medac, 2, 5, 8, MSD, 2, 5, MSD (Schering-Plough), 2, 5, 8, Mundipharma, 2, 5, 8, Mylan, 2, 5, 8, Novartis, 2, 5, 8, Pfizer, 2, 5, Pfizer (Wyeth, Hospira), 2, 5, 8, Roche, 2, 5, 8, Sanofi-Aventis, 2, 5, 8, UCB Pharma, 2, 5, 8.

To cite this abstract in AMA style:

Baraliakos X, Tsiami S, morzeck d, Fedorov K, Kiltz U, Braun J. Early Recognition of Patients with Axial Spondyloarthritis by Using a Practical Referral System – Evaluation of the Recently Proposed 2-step Strategy [abstract]. Arthritis Rheumatol. 2019; 71 (suppl 10). https://acrabstracts.org/abstract/early-recognition-of-patients-with-axial-spondyloarthritis-by-using-a-practical-referral-system-evaluation-of-the-recently-proposed-2-step-strategy/. Accessed .

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