Management Principles
Patient information and decision-making Referral to a rheumatologist and multidisciplinary team Lifestyle interventions and work participation Comorbidities and extra-articular disease Patient information and decision-making The aim of treatment is to maintain a good quality of life and function, including social participation. There is strong evidence that uncontrolled disease leads to radiograp
Patient information and decision-making
Referral to a rheumatologist and multidisciplinary team
Lifestyle interventions and work participation
Comorbidities and extra-articular disease
Patient information and decision-making
The aim of treatment is to maintain a good quality of life and function, including social participation. There is strong evidence that uncontrolled disease leads to radiographic progression, and that physical disability is a result of high disease activity and structural damage.[28-30] Importantly, there is now a choice of therapies to control inflammation in axSpA. Control of active disease can lead to improvements in physical function, HRQoL and work productivity.[31]
A management plan should be developed based on shared decision-making between patients and clinicians, according to the patient’s values, goals, preferences and comorbidities. Patient education should offer information about axSpA and its complications, including disease assessment modalities, treatment goals, medications and adherence. A rheumatology nurse can offer patient education and support, with positive effects on adherence to therapy and on HRQoL.[32-34] Treatment should be individualised according to patient characteristics, clinical features including extra-articular features, comorbidities and psychosocial factors.
Interventions including pharmacological therapy, physical activity, disease-related problem-solving, emotional well-being, communication skills and use of community resources, including patient support organisations, should be emphasised.
Referral to a rheumatologist and multidisciplinary team
All axSpA patients should ideally be seen by a rheumatologist, particularly those with diagnostic uncertainty, persistent moderate or high disease activity, functional impairment, or extra-articular disease. Care of the axSpA patient requires a multidisciplinary holistic approach that might include a dermatologist, gastroenterologist, ophthalmologist, occupational therapist, podiatrist, physiotherapist, biokineticist, pain specialist, clinical psychologist or social worker, as appropriate.
Lifestyle interventions and work participation
The importance of a healthy lifestyle, including smoking cessation, physical therapy and participation in patient support groups should be encouraged.[35-37] Exercise is a cornerstone in the management of axSpA, with demonstrated benefits on disease outcomes independent of pharmacological treatment.[35,38-40] Work participation may have positive effects on health outcomes, and SpA patients should be encouraged to continue formal or informal work.[41]
Comorbidities and extra-articular disease
The majority of axSpA patients have ≥1 comorbidity leading to premature mortality, functional impairment and reduced HRQoL.[42] Accelerated atherosclerosis and cardiovascular events, infections and osteoporosis are the major comorbidities in axSpA, and need regular screening and evidence-based management.[43] Additional comorbidities include chronic fatigue, depression, anxiety, degenerative joint disease, hypertension, dyslipidaemia, obesity and central pain sensitisation syndromes such as fibromyalgia syndrome.[44]
Screening for hepatitis B, hepatitis C, HIV and tuberculosis should be done at presentation, and repeated as clinically indicated. The vaccination status, pregnancy plans, contraception and lactational status (if relevant) of the patient should be regularly reviewed and discussed.
Maharaj, A. B., et al. (2024). South African Rheumatism and Arthritis Association 2024 guidelines for the management of axial spondyloarthritis. South African Medical Journal, 114(10), e2668.