DENVER – Spondyloarthritis experts have zeroed in on a simple and effective screening and referral strategy for nonrheumatologists to use in deciding which patients with chronic low back pain to send to rheumatologists for definitive diagnosis and treatment of axial spondyloarthritis.
The goal is to reduce the unacceptably long delay to diagnosis of axial spondyloarthritis – on average, 7 years – without flooding rheumatologists with enormous numbers of patients who have mechanical low back pain, a vastly more common yet generally self-limited condition, Dr. Abhijeet Danve explained at the annual meeting of the Spondyloarthritis Research and Treatment Network (SPARTAN).
He presented a systematic review of seven studies that examined various screening and referral strategies in the diagnosis of axial spondyloarthritis (axSpA). The studies totaled more than 3,300 patients with chronic low back pain.
Two key conclusions jumped out from this structured review: One, simple referral strategies and considerably more complex approaches work equally well, resulting in 35%-45% of referred patients ultimately being diagnosed by a rheumatologist as having axSpA.
And two, one strategy emerged on balance as the clear winner: “In our opinion, referring patients with chronic low back pain for more than 3 months, age of onset less than 45 years, and who meet one of three criteria – inflammatory back pain, HLA- [human leukocyte antigen] B27-positivity, or sacroiliitis on imaging – to a rheumatologist for assessment of possible axSpA would be convenient, practical, and widely acceptable,” according to Dr. Danve of Yale University, New Haven, Conn.
The more of these three criteria a patient possessed, the greater the rate of rheumatologist-diagnosed axSpa. If, for example, a patient under age 45 years with a history of low back pain for more than 3 months had classic inflammatory back pain but was HLA-B27-negative and didn’t show sacroiliitis on imaging, the rate of a confirmed diagnosis of axSpa was 25%. The axSpa diagnosis rate rose to 45% with two positive criteria and jumped to 75% in those who met all three criteria.
With appropriate application of any of the strategies evaluated in the systematic review, rheumatologists can expect to see two to three people with chronic low back pain in order to identify one patient with axSpA, he added.
SPARTAN is gearing up for a major educational initiative aimed at primary care physicians, orthopedists, physical therapists, and chiropractors. The goal is to improve early recognition of possible axSpA and bring affected patients to rheumatologists for definitive diagnosis and specialized care. Of note, Dr. Danve’s senior coinvestigator in the referral strategy study was Dr. Atul Deodhar, SPARTAN chair and professor of medicine and medical director of rheumatology clinics at Oregon Health and Science University, Portland.