Spondyloarthritis in over 16s:
diagnosis and management
NICE guideline
NG65
Published: 28 February 2017
Last updated: 02 June 2017
Recommendations
People have the right to be involved in discussions
and make informed decisions about their care, as
described in NICE's information on making decisions
about your care (https://www.nice.org.uk/about/nice-
communities/public-involvement/your-care).
Making decisions using NICE guidelines
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programmes/nice-guidance/nice-guidelines/using-
NICE-guidelines-to-make-decisions) explains how we
use words to show the strength (or certainty) of our
recommendations, and has information about
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professional guidelines, standards and laws (including
on consent and mental capacity), and safeguarding.
Spondyloarthritis is a group of inflammatory conditions that
have a range of manifestations. Spondyloarthritis may be
predominantly:
axial:
ankylosing spondylitis (radiographic axial
spondyloarthritis)
non-radiographic axial spondyloarthritis or
peripheral:
psoriatic arthritis
reactive arthritis
enteropathic spondyloarthritis.
People with predominantly axial spondyloarthritis may have
additional peripheral symptoms, and vice versa.
Axial presentations of spondyloarthritis are often
misdiagnosed as mechanical low back pain, leading to
delays in access to effective treatments. Peripheral
presentations are often seen as unrelated joint or tendon
problems, and can be misdiagnosed because problems can
move around between joints.
1.1 Recognition and referral in
non-specialist care settings
1.1.1 Do not rule out the possibility that a person has
spondyloarthritis solely on the presence or absence
of any individual sign, symptom or test result. [2017]
Suspecting spondyloarthritis
1.1.2 Recognise that spondyloarthritis can have diverse
symptoms and be difficult to identify, which can lead
to delayed or missed diagnoses. Signs and
symptoms may be musculoskeletal (for example,
inflammatory back pain, enthesitis and dactylitis) or
extra-articular (for example, uveitis and psoriasis
[including psoriatic nail symptoms]). Risk factors
include recent genitourinary infection and a family
history of spondyloarthritis or psoriasis. [2017]
1.1.3 Be aware that axial and peripheral spondyloarthritis
may be missed, even if the onset is associated with
established comorbidities (for example, uveitis,
psoriasis, inflammatory bowel disease [Crohn's
disease or ulcerative colitis], or a gastrointestinal or
genitourinary infection). [2017]
1.1.4 Be aware that axial spondyloarthritis:
affects a similar number of women as men
can occur in people who are human leukocyte
antigen B27 (HLA‑B27) negative
may be present despite no evidence of sacroiliitis
on a plain film X‑ray. [2017]
Referral for suspected axial
spondyloarthritis
1.1.5 If a person has low back pain that started before the
age of 45 years and has lasted for longer than
3 months, refer the person to a rheumatologist for a
spondyloarthritis assessment if 4 or more of the
following additional criteria are also present:
low back pain that started before the age of
35 years (this further increases the likelihood that
back pain is due to spondyloarthritis compared
with low back pain that started between 35 and
44 years)
waking during the second half of the night
because of symptoms
buttock pain
improvement with movement
improvement within 48 hours of taking non-
steroidal anti-inflammatory drugs (NSAIDs)
a first-degree relative with spondyloarthritis
current or past arthritis
current or past enthesitis
current or past psoriasis.
If exactly 3 of the additional criteria are present,
perform an HLA‑B27 test. If the test is positive,
refer the person to a rheumatologist for a
spondyloarthritis assessment. [2017]
1.1.6 If the person does not meet the criteria in
recommendation 1.1.5 but clinical suspicion of axial
spondyloarthritis remains, advise the person to seek
repeat assessment if new signs, symptoms or risk
factors listed in recommendation 1.1.5 develop. This
may be especially appropriate if the person has
current or past inflammatory bowel disease (Crohn's
disease or ulcerative colitis), psoriasis or uveitis (see
recommendation 1.1.12 for guidance on referral for
immediate [same‑day] ophthalmological assessment
for people with acute anterior uveitis). [2017]
Referral for suspected psoriatic arthritis
and other peripheral spondyloarthritides
1.1.7 For guidance on identifying spondyloarthritis in
people with an existing diagnosis of psoriasis, see
assessment and referral for psoriatic arthritis in the
NICE guideline on psoriasis
(https://www.nice.org.uk/guidance/cg153/chapter/1-
Guidance#assessment-and-referral-for-psoriatic-
arthritis). [2017]
1.1.8 Urgently refer people with suspected new‑onset inflammatory arthritis to a
rheumatologist for a spondyloarthritis assessment, unless rheumatoid
arthritis, gout or acute calcium pyrophosphate (CPP) arthritis ('pseudogout') is
suspected. If rheumatoid arthritis is suspected, see referral for specialist
treatment in the NICE guideline on rheumatoid arthritis in adults
(https://www.nice.org.uk/guidance/CG79/chapter/Recommendations#referral-
for-specialist-treatment). [2017]
1.1.9 Refer people with dactylitis to a rheumatologist for a
spondyloarthritis assessment. [2017]
1.1.10 Refer people with enthesitis without apparent
mechanical cause to a rheumatologist for a
spondyloarthritis assessment if:
it is persistent or
it is in multiple sites or
any of the following are also present:
back pain without apparent mechanical cause
current or past uveitis (see
recommendation 1.1.12 for guidance on
immediate [same‑day] ophthalmological
assessment for people with acute anterior
uveitis)
current or past psoriasis
gastrointestinal or genitourinary infection
inflammatory bowel disease (Crohn's disease or
ulcerative colitis)
a first-degree relative with spondyloarthritis or
psoriasis. [2017]
Recognising psoriasis
1.1.11 If a person with suspected spondyloarthritis has
signs or symptoms of undiagnosed psoriasis, follow
the recommendations in the NICE guideline on
psoriasis
(https://www.nice.org.uk/guidance/cg153/chapter/1-
Guidance). [2017]
Referral for suspected acute anterior
uveitis
1.1.12 Refer people for an immediate (same‑day)
ophthalmological assessment if they have symptoms
of acute anterior uveitis (for example, eye pain, eye
redness, sensitivity to light or blurred vision). [2017]
Case-finding in people with acute anterior
uveitis
1.1.13 Ophthalmologists should ask people with acute
anterior uveitis whether they have:
consulted their GP about joint pains or
experienced low back pain that started before the
age of 45 years and has lasted for longer than
3 months. [2017]
1.1.14 If the person meets either of the criteria in
recommendation 1.1.13, establish whether they have
psoriasis or skin complaints that appear psoriatic on
physical examination.
If they do, refer the person to a rheumatologist for
a spondyloarthritis assessment.
If they do not, perform an HLA‑B27 test. If the test
is positive, refer the person to a rheumatologist for
a spondyloarthritis assessment. [2017]
1.2 Diagnosing spondyloarthritis
in specialist care settings
Diagnostic criteria for suspected
spondyloarthritis
1.2.1 In specialist care settings, consider using validated
spondyloarthritis criteria to guide clinical judgement
when diagnosing spondyloarthritis. Examples
include:
general spondyloarthritis criteria:
Amor
European Spondyloarthropathy Study Group
(ESSG)
axial spondyloarthritis criteria:
Assessment of Spondyloarthritis International
Society (ASAS; axial)
Berlin
Rome
modified New York
peripheral spondyloarthritis criteria:
ASAS (peripheral)
Classification of Psoriatic Arthritis (CASPAR)
French Society of Rheumatology (reactive
arthritis). [2017]
1.2.2 Do not rule out a diagnosis of spondyloarthritis solely
on the basis of a negative HLA‑B27 result. [2017]
1.2.3 Do not rule out a diagnosis of spondyloarthritis if a
person's C‑reactive protein (CRP) and erythrocyte
sedimentation rate (ESR) are normal. [2017]
Imaging for suspected axial
spondyloarthritis
Initial investigation using X‑ray
1.2.4 Offer plain film X‑ray of the sacroiliac joints for
people with suspected axial spondyloarthritis, unless
the person is likely to have an immature skeleton.
[2017]
1.2.5 Diagnose ankylosing spondylitis if the plain film X‑ray
shows sacroiliitis meeting the modified New York
criteria (bilateral grade 2 to 4 or unilateral grade 3 to
4 sacroiliitis). [2017]
1.2.6 If the plain film X‑ray does not show sacroiliitis
meeting modified New York criteria (bilateral grade 2
to 4 or unilateral grade 3 to 4 sacroiliitis), or an X‑ray
is not appropriate because the person's skeleton is
not fully mature, request unenhanced MRI using an
inflammatory back pain protocol. [2017]
Subsequent investigation using MRI
1.2.7 Radiologists receiving a request for an inflammatory
back pain MRI should perform short T1 inversion
recovery (STIR) and T1 weighted sequences of the
whole spine (sagittal view), and sacroiliac joints
(coronal oblique view). [2017]
1.2.8 Use the ASAS/Outcome Measures in Rheumatology
(OMERACT) MRI criteria to interpret the MRI as
follows:
If the MRI meets the ASAS/OMERACT MRI criteria:
diagnose non-radiographic axial
spondyloarthritis.
If the MRI does not meet the ASAS/OMERACT MRI
criteria:
do not exclude the possibility of axial
spondyloarthritis
consider specialist musculoskeletal radiology
review if there is disparity between the clinical
suspicion and imaging findings, particularly in
people with an immature skeleton
offer an HLA‑B27 test if it has not already been
done. If positive, base the diagnosis of non-
radiographic axial spondyloarthritis on clinical
features, for example, using the clinical 'arm' of
the ASAS axial classification criteria. [2017]
1.2.9 If a diagnosis of axial spondyloarthritis cannot be
confirmed and clinical suspicion remains high,
consider a follow‑up MRI. [2017]
Other types of imaging for diagnosing axial
spondyloarthritis
1.2.10 Do not offer scintigraphy for people with suspected
axial spondyloarthritis. [2017]
Imaging for suspected psoriatic arthritis
and other peripheral spondyloarthritides
1.2.11 Offer plain film X‑ray of symptomatic hands and feet
for people with suspected peripheral
spondyloarthritis in these areas. [2017]
1.2.12 If a diagnosis cannot be made from the plain film
X‑ray, consider ultrasound of:
the hands and feet to assess for joint involvement
suspected enthesitis sites. [2017]
1.2.13 Consider plain film X‑rays, ultrasound and/or MRI of
other peripheral and axial symptomatic sites. [2017]
1.2.14 Interpret a positive HLA‑B27 result as increasing the
likelihood of peripheral spondyloarthritis. [2017]
1.2.15 If a diagnosis of peripheral spondyloarthritis is
confirmed, offer plain film X‑ray of the sacroiliac
joints to assess for axial involvement, even if the
person does not have any symptoms. [2017]
Antibody testing for suspected reactive
arthritis
1.2.16 Do not routinely test for infective antibody status to
diagnose reactive arthritis in people with a history of
gastrointestinal infection. [2017]
1.3 Information and support
Information about spondyloarthritis
1.3.1 Provide people with spondyloarthritis, and their
family members or carers (as appropriate), with
information that is:
available on an ongoing basis
relevant to the stage of the person's condition
tailored to the person's needs.
For more guidance on providing information to
people and discussing their preferences with
them, see the NICE guideline on patient
experience in adult NHS services
(https://www.nice.org.uk/guidance/cg138). [2017]
1.3.2 Provide explanations and information about
spondyloarthritis, for example:
what spondyloarthritis is
diagnosis and prognosis
treatment options (pharmacological and non-
pharmacological), including possible side effects
likely symptoms and how they can be managed
flare episodes and extra-articular symptoms
self-help options
opportunities for people with spondyloarthritis to
be involved in research
which healthcare professionals will be involved
with the person's care and how to get in touch
with them
information about employment rights and ability to
work
local support groups, online forums and national
charities, and how to get in touch with them.
[2017]
Information about disease flares
1.3.3 Advise people with spondyloarthritis about the
possibility of experiencing flare episodes and extra-
articular symptoms. [2017]
1.3.4 Consider developing a flare management plan that is
tailored to the person's individual needs, preferences
and circumstances. [2017]
1.3.5 When discussing any flare management plan,
provide information on:
access to care during flares (including details of a
named person to contact [for example, a specialist
rheumatology nurse])
self-care (for example, exercises, stretching and
joint protection)
pain and fatigue management
potential changes to medicines
managing the impact on daily life and ability to
work. [2017]
1.4 Pharmacological management
of spondyloarthritis
See the MHRA's safety advice on Janus kinase (JAK)
inhibitors (April 2023) (https://www.gov.uk/drug-safety-
update/janus-kinase-jak-inhibitors-new-measures-to-
reduce-risks-of-major-cardiovascular-events-malignancy-
venous-thromboembolism-serious-infections-and-
increased-mortality). See terms used in this guideline for a
description and examples of JAK inhibitors (terms-used-in-
this-guideline#janus-kinase-jak-inhibitor).
1.4.1 If people with spondyloarthritis and their clinicians
consider there to be a range of suitable medicines,
after discussing the advantages and disadvantages
of all the options, the least expensive should be
used. Administration costs, dosages, price per dose
and commercial arrangements should all be taken
into account. [2025]
Axial spondyloarthritis
Initial pharmacological treatment
1.4.2 Offer an NSAID at the lowest effective dose to people
with pain associated with axial spondyloarthritis, and
think about appropriate clinical assessment, ongoing
monitoring of risk factors, and the use of
gastroprotective treatment. [2017]
1.4.3 If an NSAID taken at the maximum tolerated dose for
2 to 4 weeks does not provide adequate pain relief,
consider switching to another NSAID. [2017]
Further pharmacological treatment for active
ankylosing spondylitis
1.4.4 For medicines recommended as options in NICE
technology appraisal guidance for treating active
ankylosing spondylitis in adults, if the condition has a
Bath Ankylosing Spondylitis Disease Activity Index
(BASDAI) score of 4 units or more and a spinal visual
analogue scale (VAS) of 4 cm or more, and NSAIDs
have not controlled the condition well enough or are
not tolerated, see the guidance on:
secukinumab (TA407, September 2016)
(https://www.nice.org.uk/guidance/ta407/chapter/1-
Recommendations)
adalimumab (TA383, February 2016)
(https://www.nice.org.uk/guidance/ta383/chapter/1-
Recommendations)
certolizumab pegol (TA383, February 2016)
(https://www.nice.org.uk/guidance/ta383/chapter/1-
Recommendations)
etanercept (TA383, February 2016)
(https://www.nice.org.uk/guidance/ta383/chapter/1-
Recommendations)
golimumab (TA383, February 2016)
(https://www.nice.org.uk/guidance/ta383/chapter/1-
Recommendations)
infliximab (TA383, February 2016)
(https://www.nice.org.uk/guidance/ta383/chapter/1-
Recommendations).
1.4.5 For medicines recommended as options in NICE
technology appraisal guidance for treating active
ankylosing spondylitis in adults, if the condition has a
BASDAI score of 4 units or more and a spinal VAS of
4 cm or more, and TNF-alpha inhibitors (terms-used-
in-this-guideline#tumour-necrosis-factor-tnf-alpha-
inhibitor) are not suitable or have not controlled the
condition well enough, see the guidance on:
tofacitinib (TA920, October 2023)
(https://www.nice.org.uk/guidance/ta920/chapter/1-
Recommendations)
bimekizumab (TA918, October 2023)
(https://www.nice.org.uk/guidance/ta918/chapter/1-
Recommendations)
upadacitinib (TA829, September 2022)
(https://www.nice.org.uk/guidance/ta829/chapter/1-
Recommendations)
ixekizumab (TA718, July 2021)
(https://www.nice.org.uk/guidance/ta718/chapter/1-
Recommendations)
secukinumab (TA407, September 2016)
(https://www.nice.org.uk/guidance/ta407/chapter/1-
Recommendations).
Also, follow recommendation 1.4.18 on reviewing treatment
(recommendations#reviewing-treatment).
Further pharmacological treatment for non-
radiographic axial spondyloarthritis
1.4.6 For medicines recommended as options in NICE
technology appraisal guidance for treating non-
radiographic axial spondyloarthritis in adults, if the
condition has a BASDAI score of 4 units or more and a
spinal VAS of 4 cm or more, and NSAIDs have not
controlled the condition well enough or are not
tolerated, see the guidance on:
golimumab (TA497, January 2018)
(https://www.nice.org.uk/guidance/ta497/chapter/1-
Recommendations)
adalimumab (TA383, February 2016)
(https://www.nice.org.uk/guidance/ta383/chapter/1-
Recommendations)
certolizumab pegol (TA383, February 2016)
(https://www.nice.org.uk/guidance/ta383/chapter/1-
Recommendations)
etanercept (TA383, February 2016)
(https://www.nice.org.uk/guidance/ta383/chapter/1-
Recommendations).
1.4.7 For medicines recommended as options in NICE
technology appraisal guidance for treating active non-
radiographic axial spondyloarthritis with objective
signs of inflammation (shown by elevated C-reactive
protein or MRI) in adults, if the condition has a BASDAI
score of 4 units or more and a spinal VAS of 4 cm or
more, and TNF-alpha inhibitors are not suitable or
have not controlled the condition well enough, see the
guidance on:
bimekizumab (TA918, October 2023)
(https://www.nice.org.uk/guidance/ta918/chapter/1-
Recommendations)
upadacitinib (TA861, February 2023)
(https://www.nice.org.uk/guidance/ta861/chapter/1-
Recommendations)
secukinumab (TA719, July 2021)
(https://www.nice.org.uk/guidance/ta719/chapter/1-
Recommendations)
ixekizumab (TA718, July 2021)
(https://www.nice.org.uk/guidance/ta718/chapter/1-
Recommendations).
Also, follow recommendation 1.4.18 on reviewing treatment
(recommendations#reviewing-treatment).
Psoriatic arthritis and other peripheral
spondyloarthritides
Initial pharmacological treatment
1.4.8 Consider local corticosteroid injections as
monotherapy for non-progressive monoarthritis.
[2017]
1.4.9 Offer standard disease-modifying anti-rheumatic
drugs (DMARDs) to people with:
peripheral polyarthritis
oligoarthritis
persistent or progressive monoarthritis associated
with peripheral spondyloarthritis. [2017]
1.4.10 When deciding which standard DMARD to offer, take
into account:
the person's needs, preferences and
circumstances (such as pregnancy planning and
alcohol consumption)
comorbidities such as uveitis, psoriasis and
inflammatory bowel disease
disease characteristics
potential side effects. [2017]
1.4.11 If a standard DMARD taken at the maximum tolerated
dose for at least 3 months does not provide adequate
relief from symptoms, consider switching to or
adding another standard DMARD. [2017]
1.4.12 Consider NSAIDs as an adjunct to DMARDs or to
manage symptoms. Use oral NSAIDs at the lowest
effective dose for the shortest possible period of
time, and think about appropriate clinical
assessment, ongoing monitoring of risk factors, and
the use of gastroprotective treatment. [2017]
1.4.13 If NSAIDs do not provide adequate relief from
symptoms, consider corticosteroid injections (local
or intramuscular) or short-term oral steroid therapy
as an adjunct to DMARDs to manage symptoms.
[2017]
1.4.14 If extra-articular disease is adequately controlled by
an existing standard DMARD but peripheral
spondyloarthritis is not, consider adding another
standard DMARD. [2017]
Further pharmacological treatment for active
psoriatic arthritis
1.4.15 For medicines recommended as options in NICE
technology appraisal guidance for treating active
psoriatic arthritis (terms-used-in-this-
guideline#active-psoriatic-arthritis) in adults when the
condition has not responded to adequate trials of at
least 2 standard DMARDs, either individually or in
combination, see the guidance on:
tofacitinib (TA543, October 2018)
(https://www.nice.org.uk/guidance/ta543/chapter/1-
Recommendations)
ixekizumab (TA537, August 2018)
(https://www.nice.org.uk/guidance/ta537/chapter/1-
Recommendations)
certolizumab pegol (TA445, May 2017)
(https://www.nice.org.uk/guidance/ta445/chapter/1-
Recommendations)
secukinumab (TA445, May 2017)
(https://www.nice.org.uk/guidance/ta445/chapter/1-
Recommendations)
apremilast (TA433, February 2017)
(https://www.nice.org.uk/guidance/ta433/chapter/1-
Recommendations)
golimumab (TA220, April 2011)
(https://www.nice.org.uk/guidance/ta220/chapter/1-
Guidance)
adalimumab (TA199, August 2010)
(https://www.nice.org.uk/guidance/ta199/chapter/1-
Recommendations)
etanercept (TA199, August 2010)
(https://www.nice.org.uk/guidance/ta199/chapter/1-
Recommendations)
infliximab (TA199, August 2010)
(https://www.nice.org.uk/guidance/ta199/chapter/1-
Recommendations)
or, if a TNF-alpha inhibitor is contraindicated, see
the guidance on:
bimekizumab (TA916, October 2023)
(https://www.nice.org.uk/guidance/ta916/chapter/1-
Recommendations)
guselkumab (TA815, August 2022)
(https://www.nice.org.uk/guidance/ta815/chapter/1-
Recommendations)
upadacitinib (TA768, February 2022)
(https://www.nice.org.uk/guidance/ta768/chapter/1-
Recommendations)
ustekinumab (TA340, March 2017)
(https://www.nice.org.uk/guidance/ta340/chapter/1-
Guidance).
1.4.16 For medicines recommended as options in NICE
technology appraisal guidance for treating active
psoriatic arthritis in adults when at least 1 biological
DMARD (terms-used-in-this-guideline#biological-
dmard) has not controlled the condition well enough or
is not tolerated, see the guidance on:
bimekizumab (TA916, October 2023)
(https://www.nice.org.uk/guidance/ta916/chapter/1-
Recommendations)
guselkumab (TA815, August 2022)
(https://www.nice.org.uk/guidance/ta815/chapter/1-
Recommendations)
risankizumab (TA803, July 2022)
(https://www.nice.org.uk/guidance/ta803/chapter/1-
Recommendations), only if the person has moderate
to severe psoriasis
upadacitinib (TA768, February 2022)
(https://www.nice.org.uk/guidance/ta768/chapter/1-
Recommendations)
tofacitinib (TA543, October 2018)
(https://www.nice.org.uk/guidance/ta543/chapter/1-
Recommendations)
ixekizumab (TA537, August 2018)
(https://www.nice.org.uk/guidance/ta537/chapter/1-
Recommendations)
certolizumab pegol (TA445, May 2017)
(https://www.nice.org.uk/guidance/ta445/chapter/1-
Recommendations)
secukinumab (TA445, May 2017)
(https://www.nice.org.uk/guidance/ta445/chapter/1-
Recommendations)
ustekinumab (TA340, March 2017)
(https://www.nice.org.uk/guidance/ta340/chapter/1-
Guidance).
For tofacitinib, ixekizumab, certolizumab pegol,
secukinumab and ustekinumab, previous biological
DMARD treatment should include a TNF-alpha
inhibitor.
Also, follow recommendation 1.4.18 on reviewing treatment
(recommendations#reviewing-treatment).
Reactive arthritis
1.4.17 After treating the initial infection, do not offer long-
term (4 weeks or longer) treatment with antibiotics
solely to manage reactive arthritis caused by a
gastrointestinal or genitourinary infection. [2017]
Reviewing treatment
1.4.18 For adults with spondyloarthritis who are receiving a
biological or targeted synthetic DMARD (listed in
recommendations 1.4.4 to 1.4.7, 1.4.15 and 1.4.16),
continue treatment only if there is clear evidence of
response (see definitions of response and
timeframes in the relevant NICE technology appraisal
guidance). [2025]
1.5 Non-pharmacological
management of spondyloarthritis
1.5.1 Refer people with axial spondyloarthritis to a
specialist physiotherapist to start an individualised,
structured exercise programme, which should
include:
stretching, strengthening and postural exercises
deep breathing
spinal extension
range of motion exercises for the lumbar, thoracic
and cervical sections of the spine
aerobic exercise. [2017]
1.5.2 Consider hydrotherapy as an adjunctive therapy to
manage pain and maintain or improve function for
people with axial spondyloarthritis. [2017]
1.5.3 Consider a referral to a specialist therapist (such as a
physiotherapist, occupational therapist, hand
therapist, orthotist or podiatrist) for people with
spondyloarthritis who have difficulties with any of
their everyday activities. The specialist therapist
should:
assess people's needs
provide advice about physical aids
arrange periodic reviews to assess people's
changing needs. [2017]
1.6 Surgery for spondyloarthritis
1.6.1 Do not refer people with axial spondyloarthritis to a
complex spinal surgery service to be assessed for
spinal deformity correction unless the spinal
deformity is:
significantly affecting their quality of life and
severe or progressing despite optimal non-
surgical management (including physiotherapy).
[2017]
1.6.2 If a person with axial spondyloarthritis presents with
a suspected spinal fracture, refer them to a specialist
to confirm the spinal fracture and carry out a stability
assessment. After the stability assessment, the
specialist should refer people with a potentially
unstable spinal fracture to a spinal surgeon. [2017]
1.7 Managing flares
1.7.1 Manage flares in either specialist care or primary
care depending on the person's needs. [2017]
1.7.2 When managing flares in primary care, seek advice
from specialist care as needed, particularly for
people who:
have recurrent or persistent flares
are taking biological or targeted synthetic
DMARDs
have comorbidities that may affect treatment or
management of flares. [2017]
1.7.3 Be aware that uveitis can occur during flare
episodes. See recommendation 1.1.12 for guidance on
immediate (same‑day) ophthalmological assessment
for people with acute anterior uveitis. [2017]
1.8 Long-term complications
1.8.1 For guidance on monitoring long-term
pharmacological treatments, see the NICE guideline
on medicines optimisation
(https://www.nice.org.uk/guidance/ng5). [2017]
1.8.2 Take into account the adverse effects associated
with NSAIDs and DMARDs when monitoring
spondyloarthritis in primary care. [2017]
1.8.3 Advise people that there may be a greater risk of skin
cancer in people treated with TNF\u2011\alpha
inhibitors (terms-used-in-this-guideline#tumour-
necrosis-factor-tnf-alpha-inhibitor). [2017]
1.8.4 Discuss risk factors for cardiovascular comorbidities
with all people with spondyloarthritis. [2017]
1.8.5 Consider regular osteoporosis assessments (every
2 years) for people with axial spondyloarthritis. Be
aware that bone mineral density measures may be
elevated on spinal dual‑energy X‑ray absorptiometry
(DEXA) due to the presence of syndesmophytes and
ligamentous calcification, whereas hip
measurements may be more reliable. [2017]
1.8.6 Advise people with axial spondyloarthritis that they
may be prone to fractures, and should consult a
healthcare professional following falls or physical
trauma, particularly in the event of increased
musculoskeletal pain. [2017]
1.9 Organisation of care
Coordinating care across settings
1.9.1 Commissioners should ensure that local
arrangements are in place to coordinate care for
people across primary and secondary (specialist)
care. These should cover:
prescribing NSAIDs and DMARDs
monitoring NSAIDs and DMARDs
managing flares
ensuring prompt access to specialist
rheumatology care when needed
ensuring prompt access to other specialist
services to manage comorbidities and extra-
articular symptoms. [2017]
1.9.2 Ensure that people with spondyloarthritis have
access to specialist care in primary or secondary
care settings throughout the disease course to
ensure optimal long-term spondyloarthritis
management (see section 1.7 for arrangements for
managing flares (recommendations#managing-
flares)). [2017]
1.9.3 Ensure that there is effective communication and
coordination between all healthcare professionals
involved in the person's care, particularly if the
person has comorbidities or extra-articular
symptoms. [2017]
1.9.4 Ensure that there is communication and coordination
between rheumatology and other relevant
specialities (such as dermatology, gastroenterology
and ophthalmology). This is particularly important for
people who:
are already receiving DMARDs for another
condition
need to start taking DMARDs for another
condition. [2017]
1.9.5 For guidance on managing the transition of young
people with juvenile idiopathic arthritis to adult
services, see the NICE guideline on transition from
children's to adults' services for young people using
health or social care services
(https://www.nice.org.uk/guidance/ng43). [2017]
© NICE (National Institute for Health and Care Excellence) 2025. All rights reserved. Subject to Notice of rights
(https://www.nice.org.uk/terms-and-conditions#notice-of-rights).
