Are you sure it’s just back pain? What to do if it’s axial spondyloarthritis

Don’t just think of it as ‘simple’ back pain. Because those living with axial spondyloarthritis may face far more complex clinical complications, involving the bowel, eyes and skin. Unfortunately, precisely because of its complexity, the clinical picture does not allow for a prompt and correct diagnosis, as the condition is often underestimated and dismissed as mere postural pain or something similar. Generally, the condition – which mainly affects young adults – may not be correctly recognised until 8–10 years after its onset, a period during which the inflammation has time to progress and cause damage. Experts are highlighting this fact to mark the World Day dedicated to the condition in early October.

But here are the symptoms that should give cause for concern and serve as a warning: the pain has lasted for at least three months, worsens at night and improves with movement. As Andrea Doria, President of the Italian Society of Rheumatology, pointed out on that occasion, the condition ‘represents a group of diseases that mainly affect the spine and the sacroiliac joints but can also affect other joints and various organs’. In Italia, there are an estimated 15 new cases per 100,000 inhabitants per year, amounting to over 8,000–9,000 diagnoses. Unlike in the past, when spondyloarthritis was considered almost exclusively a male condition, today the ratio between men and women is more balanced (approximately 3 to 2). ‘The condition typically first appears before the age of 40–45, often as early as around 30,’ concludes the expert. ‘Recently, we have made significant progress in understanding and managing the disease, but the challenge of diagnosis remains to be resolved, as recognising it early can change patients’ lives.’

“Axial spondyloarthritis is a systemic condition: as well as the spine, it can also affect other parts of the body,” comments Roberta Ramonda, Head of Rheumatology at the Padua University Hospital and Vice-President of the Italian Foundation for Research in Rheumatology (FIRA). The most common manifestations include uveitis – that is, inflammation of the eye – inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis, and psoriasis. This is why a multidisciplinary approach involving rheumatologists, gastroenterologists, ophthalmologists and dermatologists is essential. Sometimes the diagnosis may arise precisely from the suspicions of other specialists: it may be the ophthalmologist, faced with recurrent uveitis, or the gastroenterologist in patients with chronic bowel diseases and pain in the spine or other joints, who refers the patient for a rheumatological assessment.”

“Alongside medication, lifestyle also plays a key role,” says Ramonda. “Physical exercise is an integral part of treatment: it improves mobility, reduces stiffness and helps to manage pain. Low-impact activities such as swimming and cycling are particularly beneficial, along with stretching and muscle-strengthening exercises. Diet also has a significant impact: a Mediterranean-style diet, rich in fibre and polyphenols, can have an anti-inflammatory effect and contribute to the patient’s general well-being.” When it comes to treatment, an interdisciplinary approach is increasingly the key to effective care, with a ‘tailor-made’, personalised therapy adapted to the clinical characteristics of the disease and the individual. In this regard, the treatment pathway involves several stages: it begins with non-steroidal anti-inflammatory drugs (NSAIDs), whilst if the symptoms of the disease persist, biologics such as TNF inhibitors and interleukin-17 and -23 inhibitors may be used; these are the standard of care for the most active forms of the disease. In addition, JAK1 inhibitors are also being used increasingly.