Spondyloarthropathies

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The one-minute consultant answer

The spondyloarthropathies (SpA) are a family of interrelated inflammatory rheumatic diseases unified by four core features: inflammatory back pain, enthesitis (inflammation at the bone-tendon/ligament junction), the genetic marker HLA-B27, and an absence of rheumatoid factor (hence seronegative). The family includes ankylosing spondylitis (AS) and non-radiographic axial SpA (the axial subgroup), psoriatic arthritis (PsA), reactive arthritis, and enteropathic arthritis (associated with inflammatory bowel disease). The clinical hallmark is inflammatory back pain — insidious onset, age under 45, improving with exercise but not rest, alternating buttock pain, and morning stiffness over 30 minutes ^[6]. Diagnosis rests on the modified New York criteria for established AS (radiographic sacroiliitis plus one clinical criterion) ^[1] and the ASAS classification criteria for axial SpA (the imaging arm or the clinical arm, applied to chronic back pain with onset under 45) ^[2]. Management follows the ASAS-EULAR 2022 recommendations: NSAIDs at full dose are first-line, physiotherapy and exercise are the non-pharmacological core, and biologic DMARDs (TNF inhibitors or IL-17 inhibitors) are indicated when disease activity (ASDAS at least 2.1 or BASDAI at least 4) persists despite at least two NSAIDs ^[5]. JAK inhibitors (tofacitinib, upadacitinib) are approved after biologic failure ^[10]. Conventional synthetic DMARDs (sulfasalazine, methotrexate) are ineffective for pure axial disease but useful for peripheral arthritis.

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References12ShowHide

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