Synopsis
Recognise axial spondyloarthritis before radiographic damage, use the recommended imaging sequence, combine exercise and anti-inflammatory treatment, and escalate persistent active disease through specialist biologic pathways.
- Consider axial spondyloarthritis when chronic back pain begins before age forty-five, especially with night waking, buttock pain and improvement with movement rather than rest.
- Ask about uveitis, psoriasis, inflammatory bowel disease, enthesitis, dactylitis, peripheral arthritis and first-degree family history.
- Normal CRP, negative HLA-B27 and normal radiographs do not exclude axial spondyloarthritis.
- Follow the NICE imaging sequence: sacroiliac radiography when appropriate, followed by a protocolled MRI if suspicion remains and radiographs are nondiagnostic.
- Structured exercise and physiotherapy addressing spinal mobility, posture, strength, aerobic fitness and breathing are central long-term treatments.
- An NSAID trial may improve pain and stiffness when gastrointestinal, renal and cardiovascular risk permits; review effectiveness and toxicity rather than prescribing indefinitely by default.
- For persistently active disease after appropriate non-pharmacological and conventional care, TNF, IL-17 or JAK inhibition may be selected under the applicable NICE approval; no class is generally superior for musculoskeletal efficacy. Choose jointly for licence and eligibility, prior response, comorbidity and extra-musculoskeletal disease. Prefer a monoclonal TNF inhibitor for recurrent or moderate-to-severe uveitis; in active inflammatory bowel disease prefer monoclonal TNF or JAK inhibition and do not start an IL-17 inhibitor.
- Protect the ankylosed spine after trauma: maintain alignment, obtain urgent CT and add MRI after CT for a neurological abnormality potentially due to cord injury; image the rest of the spine when a new fracture is identified.
Key red flags
Unilateral eye pain, photophobia, redness and blurred vision requires same-day ophthalmic assessment to prevent sight-threatening complications.
New severe focal pain, deformity or neurological change after minor trauma in an ankylosed spine requires emergency immobilisation, imaging and spinal review.
Investigation priorities
Identify definite structural sacroiliitis and alternative bony pathology in the NICE diagnostic sequence.
Management branches
Chronic back pain begins before forty-five with inflammatory or extra-articular features.
- Document onset, night symptoms, movement response, buttock pain, family history and psoriasis, uveitis, bowel, entheseal and peripheral-joint features.
- Refer according to NICE criteria, obtain HLA-B27 and markers when useful, and follow sacroiliac radiography then protocolled MRI when needed.
- Retain specialist follow-up or reassessment when early imaging is negative but the phenotype remains convincing rather than converting the diagnosis to mechanical pain automatically.
Key medicines
NaproxenCommon adult anti-inflammatory dosing is 250–500 mg orally twice daily with food, using the lowest effective dose for the shortest necessary period.Assess ulcer or bleeding, renal, heart-failure, blood-pressure, cardiovascular, anticoagulant and interaction risks and add gastroprotection when indicated. Avoid systemic NSAIDs from 20 weeks of pregnancy unless essential; use the lowest dose for the shortest time and consider fetal monitoring after several days. They are contraindicated after 28 weeks.
AdalimumabThe usual adult regimen for axial spondyloarthritis is 40 mg subcutaneously every other week under specialist prescribing and product information.Do not start during active serious infection and stop for a new serious infection; screen for tuberculosis and hepatitis and update immunisation first. Avoid live vaccines during treatment, and seek an alternative in demyelinating disease. Adalimumab is contraindicated in NYHA III or IV heart failure. If continued through pregnancy, document exposure and the BSR plan to defer infant live vaccines until 6 months.