Challenges of diagnosis and management of axial spondyloarthritis in North Africa and the Middle East: An expert consensus
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Challenges of diagnosis and management of axial spondyloarthritis in North Africa and the Middle East: An expert consensus
Mohammed Hammoudeh 4
Sultana Abdulaziz 3
Hanan Alosaimi 2
Hanan Al-Rayes 9
Hussam Aldeen Sarakbi 8
Matouqa Baamer 7
Xenofon Baraliakos 6
Chafia Dahou Makhloufi 11
Nahid Janoudi 10
Khalid Shirazy 5
Joachim Sieper 0
Uppal Sukhbir 1
0 Klinikum Benjamin Franklin, Freien Universita ̈t Berlin , Berlin , Germany
1 Rheumatology Division, University Hospital , Sharjah , United Arab Emirates
2 Rheumatology Section, Department of Internal Medicine/ Rheumatology, Military Hospital , Jeddah , Saudi Arabia
3 Department of Medicine, King Fahad Hospital , Jeddah , Saudi Arabia
4 Department of Medicine, Weill Cornell Medical College Qatar, Hamad Medical Corporation , Doha , Qatar
5 Pfizer AfME , Media City, Dubai , United Arab Emirates
6 Rheumazentrum Ruhrgebiet, Ruhr-University Bochum , Herne , Germany
7 Department of Medicine, King Abdulaziz Hospital and Oncology Centre , Jeddah , Saudi Arabia
8 Department of Medicine, Hamad Medical Corporation , Doha , Qatar
9 Department of Medicine, Armed Force Hospital , Riyadh , Saudi Arabia
10 Department of Rheumatology, DSFH Hospital , Jeddah , Saudi Arabia
11 Department of Rheumatology, Bab El Oued Hospital , Algiers , Algeria
Axial spondyloarthritis (SpA) is a spectrum of inflammatory disease with stages characterized by both nonradiographic and radiographic sacroiliitis. Nonradiographic axial SpA is associated with health-related quality-of-life impairment and may progress to ankylosing spondylitis. Axial SpA has a low prevalence in some countries in North Africa and the Middle East, and pooling of data and resources is needed to increase understanding of the regional picture. Early diagnosis and effective treatment are required to reduce disease burden and prevent progression. Anti-TNF therapy is recommended for patients with persistently high disease activity despite conventional treatment, and has been shown to be effective in patients without radiographic damage. Diagnostic delays can
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be an obstacle to early treatment and appropriate referral strategies are needed. In some
countries, restricted access to magnetic resonance imaging and anti-TNF agents presents a
challenge. In this article, a group of experts from North Africa and the Middle East evaluated the
diagnosis and management of axial SpA with particular reference to this region.
Introduction
Axial spondyloarthritis (SpA) is a spectrum
of inflammatory disease with stages
characterized by both nonradiographic and
radiographic sacroiliitis.1 Sacroiliac joint
involvement is considered to be the hallmark
of SpA, and the disease course is
characterized by ongoing axial inflammation and
radiographic progression, associated with
restricted mobility of the spine and
decreased function.2 The Assessment of
Spondyloarthritis International Society
(ASAS) classification criteria define axial
SpA as either the presence of sacroiliitis by
radiography or by magnetic resonance
imaging (MRI) plus at least one SpA feature
(‘‘imaging arm’’), or the presence of human
leukocyte antigen (HLA)-B27 plus at least
two SpA features (‘‘clinical arm’’).3 This
diagnostic method is more reliable than
older criteria (ESSG4 or Amor5), which
were developed before MRI was widely
used. In addition, the ASAS classification
criteria enable early diagnosis and treatment
of axial SpA,6 reducing signs and symptoms
and decreasing the risk of radiographic
progression and further functional
impairment.7
Patients with nonradiographic axial SpA
are demographically similar to those with
radiographic disease (ankylosing spondylitis
[AS]).2,8 Women are more likely than men to
have nonradiographic disease, while men are
more likely than women to have
radiographic forms, and patients with AS
are more likely to have a family history of
SpA compared with those with
nonradiographic disease.2,8 Both groups are similar in
terms of comorbidities, clinical
characteristics, disease activity index (Bath Ankylosing
Spondylitis Disease Activity Index;
BASDAI), and the proportion of patients
treated with nonsteroidal anti-inflammatory
drugs (NSAIDs). Patients with AS tend to
have higher C-reactive protein (CRP) levels,
and worse function (Bath Ankylosing
Spondylitis Functional Index; BASFI) and
spinal mobility (Bath Ankylosing
Spondylitis metrology index; BASMI) than
those with nonradiographic disease. By
definition, patients with AS have radiographic
sacroiliitis, whereas those with
nonradiographic axial SpA have a lower modified
Stoke Ankylosing Spondylitis Spine Score
(mSASSS).2,8 Spinal inflammation, as
assessed by MRI, is seen in 60% of patients
with AS and 47% of those with
nonradiographic axial SpA.2
Nonradiographic axial SpA is a subset of
axial SpA in which no clear structural
damage is visible using conventional
radiography. The term includes patients with
early radiographic sacroiliitis (gra (...truncated)