Case-Based Approach for the Management of Rheumatic Diseases - Episode 2

Nr-AxSpA Diagnostic Challenges

May 26, 2020

Transcript: Sergio Schwartzman, MD: With regards, now, to nonradiographic axial spondyloarthritis, 1 of the challenges is that it takes many years—and indeed our patient exemplifies that—from the onset of symptoms to the actual diagnosis. Part of the challenge, there, is that this is a relatively new diagnosis for us. We’ve not had a classification criteria for nonradiographic axial spondyloarthritis for a long period of time. The ASAS [Assessment of SpondyloArthritis International Society] group was the first to make this distinction and that was very recently, in 2009.

So, there is a lack of knowledge across all subspecialties, with regards to nonradiographic axial spondyloarthritis as a distinct entity. And patients are frequently seen by a number of different doctors who may or may not be well educated as to this entity. For example, they can be seen by primary care physicians who do not necessarily always refer their patients to rheumatologists quickly because there is sometimes difficulty in getting an appointment. Number 2, they can be seen by orthopedic surgeons who, likewise, are not familiar with this diagnosis. Physiatrists and pain management physicians, not infrequently, are not knowledgeable of the whole concept of axial spondyloarthritis. And sometimes these patients are seen by a neurologist first because it’s back pain. Believe it or not, they’re seen by podiatrists who sometimes attribute the back pain to issues referable to the gait and the foot. And also these patients are frequently seen by chiropractors. So, the average delay, now, from the time of symptoms to the diagnosis of nonradiographic axial spondyloarthritis is 4 to 8 years.

So, how can community rheumatologists, then, make this diagnosis early? The first, obviously, is an unmet need, which we’re trying to fulfill now, and that is education. We hope that as more people become aware of this entity and this spectrum of disease that occurs in axial spondyloarthritis that they will be a lot more sensitive to this specific diagnosis. So I think that education is a critical element. I must admit, as a rheumatologist, that sometimes this diagnosis is also missed by rheumatologists and, to that point, there is an article that was published that looked at a number of different rheumatology practices and found that there were patients who had axial spondyloarthritis who are identified as having other diseases.

Overwhelmingly, the most common reason why this diagnosis is made is because back pain is very common in our community. As many as 40% to 60% of people, over time, maybe even a larger group, will have an episode of back pain, which tends to be mechanical back pain. So it's not due to an autoimmune inflammatory disease like axial spondyloarthritis. So most physicians, when they see patients with back pain do not differentiate between inflammatory back pain and mechanical back pain and assume that this is all mechanical back pain. Probably the other mistaken diagnosis and by which patients are missed as having axial spondyloarthritis is fibromyalgia.

And fibromyalgia, frequently, does include a component of back pain. Interestingly, we have found that women who have nonradiographic axial spondyloarthritis are more likely to have symptoms of fibromyalgia, meaning that their pain isn’t classic. They can have more diffuse symptoms and they can have cervical spine symptoms.

Transcript Edited for Clarity