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Spondyloarthritis

About

What is covered

This interactive flowchart covers diagnosing and managing spondyloarthritis that is suspected or confirmed in people aged 16 and over.

Updates

Updates to this interactive flowchart

7 August 2018 Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs (NICE technology appraisal guidance 537) added to managing peripheral spondyloarthritis in adults.
27 June 2018 Spondyloarthritis (NICE quality standard 170) added.
9 January 2018 Golimumab for treating non-radiographic axial spondyloarthritis (NICE technology appraisal guidance 497) added to choice of biological therapy for pain relief.
2 June 2017 Recommendation in axial spondyloarthritis updated to clarify the advice on what imaging should be done.
23 May 2017 Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs (NICE technology appraisal guidance 445) added to choice of biological therapy for psoriatic arthritis.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing spondyloarthritis in people aged 16 and over in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing and managing spondyloarthritis that is suspected or confirmed in people aged 16 and over.

Updates

Updates to this interactive flowchart

7 August 2018 Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs (NICE technology appraisal guidance 537) added to managing peripheral spondyloarthritis in adults.
27 June 2018 Spondyloarthritis (NICE quality standard 170) added.
9 January 2018 Golimumab for treating non-radiographic axial spondyloarthritis (NICE technology appraisal guidance 497) added to choice of biological therapy for pain relief.
2 June 2017 Recommendation in axial spondyloarthritis updated to clarify the advice on what imaging should be done.
23 May 2017 Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs (NICE technology appraisal guidance 445) added to choice of biological therapy for psoriatic arthritis.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Golimumab for treating non-radiographic axial spondyloarthritis (2018) NICE technology appraisal guidance 497
Apremilast for treating active psoriatic arthritis (2017) NICE technology appraisal guidance 433
Ustekinumab for treating active psoriatic arthritis (2015 updated 2017) NICE technology appraisal guidance 340
Golimumab for the treatment of psoriatic arthritis (2011) NICE technology appraisal guidance 220
Spondyloarthritis (2018) NICE quality standard 170

Quality standards

Spondyloarthritis

These quality statements are taken from the spondyloarthritis quality standard. The quality standard defines clinical best practice for spondyloarthritis and should be read in full.

Quality statements

Referral

This quality statement is taken from the spondyloarthritis quality standard. The quality standard defines clinical best practice for spondyloarthritis and should be read in full.

Quality statement

Adults with suspected axial or peripheral spondyloarthritis are referred to a rheumatologist.

Rationale

Both axial and peripheral spondyloarthritis, including psoriatic arthritis, are difficult to diagnose without specialist assessment. Delays in correctly identifying spondyloarthritis can result in significant morbidity and avoidable investigations and treatments. Referring adults with suspected spondyloarthritis to a rheumatologist will reduce delays in diagnosis and starting treatment. This will help improve outcomes, such as reducing joint and tendon damage, loss of function, pain, fatigue and quality of life.

Quality measures

Structure
a) Evidence of local arrangements to raise awareness of signs, symptoms and risk factors of axial and peripheral spondyloarthritis in primary care.
Data source: Local data collection, for example, from education programmes or awareness campaigns.
b) Evidence of local referral criteria and pathways to ensure that adults with suspected axial or peripheral spondyloarthritis are referred to a rheumatologist.
Data source: Local data collection, for example, from referral pathways or referral strategies.
Process
Proportion of adults with suspected axial or peripheral spondyloarthritis referred to a rheumatologist.
Numerator – the number in the denominator referred to a rheumatologist.
Denominator – the number of adults with suspected axial or peripheral spondyloarthritis.
Data source: Local data collection, for example, local audit of patient records.
Outcomes
a) Time from first presentation of symptoms to diagnosis for adults with spondyloarthritis.
Data source: Local data collection, for example, local audit of patient records.
b) Health-related quality-of-life score of adults with spondyloarthritis.
Data source: Local data collection, for example, survey of adults with axial spondyloarthritis using a quality-of-life questionnaire.
c) Functional ability score of adults with axial spondyloarthritis.
Data source: Local data collection, for example, survey of adults with axial spondyloarthritis using a questionnaire to assess functional ability (such as the Bath Ankylosing Spondylitis Functional Index).
d) Joint replacement surgery for adults with peripheral spondyloarthritis.
Data source: Local data collection, for example, local audit of patient records.

What the quality statement means for different audiences

Service providers (such as GP practices and musculoskeletal interface services, physiotherapy, ophthalmology, dermatology and gastroenterology services) ensure that healthcare professionals are aware of the signs, symptoms and risk factors of axial and peripheral spondyloarthritis. They develop referral criteria and pathways with rheumatology services to ensure that people with signs and symptoms of spondyloarthritis are referred to rheumatologists for assessment and diagnosis.
Healthcare professionals (such as GPs, physiotherapists, nurses, dermatologists, gastroenterologists and ophthalmologists) are aware of the signs, symptoms and risk factors of axial and peripheral spondyloarthritis, the groups of people it can affect and local referral pathways. They identify people who have signs and symptoms of spondyloarthritis and refer them to a rheumatologist for investigation and diagnosis.
Commissioners (clinical commissioning groups and NHS England) have service specifications for rheumatology that include referral criteria and referral pathways to ensure that adults presenting with signs, symptoms and risk factors of axial or peripheral spondyloarthritis are referred to a rheumatologist for investigation and diagnosis.
Adults with symptoms that suggest spondyloarthritis (a type of inflammatory arthritis) are referred to a specialist in rheumatology for assessment and tests, which may include an X-ray or a scan. People who have these assessments and tests will find out sooner whether or not they have spondyloarthritis and can start treatment earlier.

Source guidance

Spondyloarthritis in over 16s: diagnosis and management (2017) NICE guideline NG65, recommendations 1.1.5, 1.1.8, 1.1.9 and 1.1.10

Definitions of terms used in this quality statement

Suspected axial spondyloarthritis
Signs and symptoms of axial spondyloarthritis include a combination of low back pain that started before the age of 45 years and has lasted for longer than 3 months, and:
  • 4 or more of the following additional criteria:
    • 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
    • a first-degree relative with spondyloarthritis
    • current or past arthritis
    • current or past enthesitis (inflammation of a site at which a tendon or ligament attaches to bone)
    • current or past psoriasis
or
  • 3 of the above additional criteria and a positive result from a HLA-B27 test.
[NICE’s guideline on spondyloarthritis, recommendation 1.1.5 and glossary in the full guideline]
Suspected peripheral spondyloarthritis
Signs, symptoms and risk factors that indicate an adult could have psoriatic arthritis or other peripheral spondyloarthritides are:
  • new-onset inflammatory arthritis, unless rheumatoid arthritis, gout or acute calcium pyrophosphate arthritis ('pseudogout') is suspected
  • dactylitis (inflammation of a finger or toe characteristically resulting in a sausage appearance)
  • enthesitis without apparent mechanical cause 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
      • 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.
[NICE’s guideline on spondyloarthritis, recommendations 1.1.8, 1.1.9, 1.1.10 and glossary in the full guideline]

Equality and diversity considerations

There is a common misconception that axial spondyloarthritis mainly affects men. Healthcare professionals should be aware that axial spondyloarthritis affects a similar number of women as men.

Diagnosis of axial spondyloarthritis using imaging

This quality statement is taken from the spondyloarthritis quality standard. The quality standard defines clinical best practice for spondyloarthritis and should be read in full.

Quality statement

Adults with suspected axial spondyloarthritis and an X-ray that does not show sacroiliitis have an MRI using an inflammatory back pain protocol.

Rationale

No single test can diagnose axial spondyloarthritis. Blood tests for HLA-B27 may be negative in some people and not all people have raised inflammatory markers. X-rays can support a diagnosis of radiographic axial spondylitis, but in some cases it can take several years for changes to be detectable, and sometimes changes may never show on X-ray. When plain film X-ray does not show sacroiliitis, MRI using an inflammatory back pain protocol that is interpreted by a specialist with knowledge of spondyloarthritis can support the diagnosis of non-radiographic axial spondyloarthritis and enable effective treatment to start.

Quality measures

Structure
a) Evidence of local arrangements to ensure that rheumatologists and musculoskeletal interface services can access X-ray and MRI diagnostic services for people with suspected axial spondyloarthritis.
Data source: Local data collection, for example, from referral pathways or service specifications.
b) Evidence of local arrangements to ensure that a musculoskeletal radiologist interprets imaging for people with suspected axial spondyloarthritis when appropriate.
Data source: Local data collection, for example, from service specifications.
c) Evidence of an inflammatory back pain protocol outlining how to perform MRI on adults with suspected axial spondyloarthritis.
Data source: Local data collection, for example, from service protocols.
Process
a) Proportion of adults with suspected axial spondyloarthritis and an X-ray that does not show sacroiliitis that have an MRl.
Numerator – the number in the denominator that have an MRI.
Denominator – the number of adults with suspected axial spondyloarthritis who have had an X-ray that does not show sacroiliitis.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of MRIs for suspected axial spondyloarthritis in adults performed using an inflammatory back pain protocol.
Numerator – the number in the denominator performed using an inflammatory back pain protocol.
Denominator – the number of MRIs performed to investigate suspected axial spondyloarthritis in adults.
Data source: Local data collection, for example, local audit of patient records.
Outcomes
a) Time from first presentation of symptoms to diagnosis for adults with axial spondyloarthritis.
Data source: Local data collection, for example, local audit of patient records.
b) Health-related quality-of-life score of adults with axial spondyloarthritis.
Data source: Local data collection, for example, survey of adults with axial spondyloarthritis using a quality-of-life questionnaire.
c) Functional ability score of adults with axial spondyloarthritis.
Data source: Local data collection, for example, survey of adults with axial spondyloarthritis using a questionnaire to assess functional ability (such as the Bath Ankylosing Spondylitis Functional Index).

What the quality statement means for different audiences

Service providers (such as rheumatology and diagnostic imaging services) have protocols in place to ensure that X-ray is used for first-line imaging in people with suspected axial spondyloarthritis. They perform MRI only when there is no evidence of sacroiliitis meeting modified New York criteria on X-ray, or an X-ray is not appropriate because the person's skeleton is not fully mature. They ensure that MRI for suspected axial spondyloarthritis is performed using an inflammatory back pain protocol.
Healthcare professionals (such as rheumatologists and healthcare professionals in musculoskeletal interface services) request X-ray for first-line imaging in people with suspected axial spondyloarthritis unless a person is likely to have an immature skeleton. They request MRI using an inflammatory back pain protocol if there is no evidence of sacroiliitis meeting modified New York criteria on X-ray. Rheumatologists and radiologists use the Assessment of Spondyloarthritis International Society/Outcome Measures in Rheumatology MRI criteria to interpret the MRI.
Commissioners (clinical commissioning groups) have service specifications that require MRI using an inflammatory back pain protocol for people with suspected axial spondyloarthritis when there is no evidence of sacroiliitis meeting modified New York criteria on X-ray, or when an X-ray is not appropriate because the person's skeleton is not fully mature.
Adults with symptoms that suggest axial spondyloarthritis are offered an MRI scan to check for inflammation if an X-ray has not shown the condition, or if an X-ray is not appropriate because the person has not finished growing.

Source guidance

Spondyloarthritis in over 16s: diagnosis and management (2017) NICE guideline NG65, recommendation 1.2.6

Definitions of terms used in this quality statement

Sacroiliitis
Inflammation of the sacroiliac joint at the base of the spine that meets the modified New York criteria (bilateral grade 2–4 or unilateral grade 3–4 sacroiliitis).
[NICE’s guideline on spondyloarthritis, recommendation 1.2.6 and glossary in the full guideline]
Inflammatory back pain protocol
An MRI performed using short T1 inversion recovery (STIR) and T1 weighted sequences of the whole spine (sagittal view), and sacroiliac joints (coronal oblique view).
[NICE’s guideline on spondyloarthritis, recommendation 1.2.7]

Equality and diversity considerations

There is a common misconception that axial spondyloarthritis mainly affects men. Healthcare professionals should be aware that axial spondyloarthritis affects a similar number of women as men. Women are less likely to show sacroiliitis on X-ray than men, but they should still be offered X-ray for first-line imaging of suspected axial spondyloarthritis. If a person does not have an X-ray they cannot be diagnosed with radiographic axial spondyloarthritis and so are not eligible for any treatments that are only available for that indication.
Young people (around 16 to 18 years of age) with an immature skeleton are unlikely to show radiographic signs and therefore an X-ray would be inappropriate at initial presentation. It is likely that people in this group would be offered further opportunities for assessment by X-ray at a later stage in disease management.

Physiotherapy

This quality statement is taken from the spondyloarthritis quality standard. The quality standard defines clinical best practice for spondyloarthritis and should be read in full.

Quality statement

Adults with axial spondyloarthritis are referred to a specialist physiotherapist for a structured exercise programme.

Rationale

Specialist physiotherapy is a key non-pharmacological management strategy for people with axial spondyloarthritis. Structured exercise programmes that are designed and tailored by specialist physiotherapists for a person’s current and changing needs can have many benefits for people with spondyloarthritis. These include helping to reduce the impact of the disease, improving or maintaining mobility, function and quality of life, enabling self-management, and reducing pain and fatigue.

Quality measures

Structure
Evidence of local referral pathways to specialist physiotherapists for adults with axial spondyloarthritis.
Data source: Local data collection, for example, from referral pathways or referral strategies.
Process
a) Proportion of adults with axial spondyloarthritis referred to a specialist physiotherapist for a structured exercise programme.
Numerator – the number in the denominator referred to a specialist physiotherapist for a structured exercise programme.
Denominator – the number of adults with axial spondyloarthritis.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of adults with axial spondyloarthritis referred to a specialist physiotherapist for a structured exercise programme who attended the programme.
Numerator – the number in the denominator who attended the programme.
Denominator – the number of adults with axial spondyloarthritis referred to a specialist physiotherapist for a structured exercise programme.
Data source: Local data collection, for example, local audit of patient records.
Outcomes
a) Functional ability score of adults with axial spondyloarthritis.
Data source: Local data collection, for example, survey of adults with axial spondyloarthritis using a questionnaire to assess functional ability (such as the Bath Ankylosing Spondylitis Functional Index).
b) Self-reported pain score of adults with axial spondyloarthritis.
Data source: Local data collection, for example, survey of adults with axial spondyloarthritis using a questionnaire to assess pain (such as the Bath Ankylosing Spondylitis Disease Activity Index).
c) Self-reported fatigue score of adults with axial spondyloarthritis.
Data source: Local data collection, for example survey of adults with axial spondyloarthritis using a questionnaire to assess fatigue (such as the Bath Ankylosing Spondylitis Disease Activity Index).
d) Spinal mobility score of adults with axial spondyloarthritis.
Data source: Local data collection, for example, from measurements taken during a clinical examination to populate a validated tool (such as the Bath Ankylosing Spondylitis Metrology Index).

What the quality statement means for different audiences

Service providers (such as GP practices and rheumatology services) ensure that pathways are in place for adults with axial spondyloarthritis to be referred to a specialist physiotherapist to start a structured exercise programme.
Healthcare professionals (such as rheumatologists and GPs) refer adults with axial spondyloarthritis to a specialist physiotherapist to start a structured exercise programme.
Commissioners (clinical commissioning groups) commission physiotherapy services that have specialist physiotherapists in rheumatology and have service specifications that ensure that adults with axial spondyloarthritis are referred to them to start a structured exercise programme.
Adults who have axial spondyloarthritis are referred to a specialist physiotherapist who helps with joint, muscle and movement problems. The physiotherapist will tailor a plan of exercises to the person’s individual and changing needs. The aim of the exercises is to ease symptoms such as stiffness and pain, and help with mobility and fitness.

Source guidance

Spondyloarthritis in over 16s: diagnosis and management (2017) NICE guideline NG65, recommendation 1.5.1

Definitions of terms used in this quality statement

Structured exercise programme
A plan of exercises tailored to a person’s individual and changing needs that includes:
  • 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.
[NICE’s guideline on spondyloarthritis, recommendation 1.5.1]
Specialist physiotherapist
A physiotherapist with rheumatology experience and experience of treating axial spondyloarthritis.
[Expert opinion].

Information

This quality statement is taken from the spondyloarthritis quality standard. The quality standard defines clinical best practice for spondyloarthritis and should be read in full.

Quality statement

Adults with spondyloarthritis are given information about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.

Rationale

Knowing about spondyloarthritis, including the symptoms, can help people to manage their condition and know when they need support from healthcare professionals. It is important that people have information on who to contact when they need extra advice and support, such as when they have a flare, so that they can access care quickly and return to normal activities without disease progression or complications.

Quality measures

Structure
a) Evidence that written information is available for adults with spondyloarthritis about their condition, who will be involved with their care, and how and when to get in touch with them.
Data source: Local data collection, for example, information leaflets.
b) Evidence of local processes to ensure that adults with spondyloarthritis have a discussion with a healthcare professional about their condition, who will be involved with their care, and how and when to get in touch with them.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of adults with spondyloarthritis who are given written information about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.
Numerator – the number in the denominator who are given written information about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.
Denominator – the number of adults with spondyloarthritis.
Data source: Local data collection, for example, audit of electronic patient health records.
b) Proportion of adults with spondyloarthritis who have a record of a discussion about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.
Numerator – the number in the denominator who have a record of a discussion about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.
Denominator – the number of adults with spondyloarthritis.
Data source: Local data collection, for example, audit of electronic patient health records.
Outcomes
a) Adults with spondyloarthritis know how to self-manage their condition.
Data source: Local data collection, for example, survey of adults with spondyloarthritis.
b) Adults with spondyloarthritis know how to access care when they need additional support.
Data source: Local data collection, for example, survey of adults with spondyloarthritis.

What the quality statement means for different audiences

Service providers (rheumatology services) ensure that healthcare professionals have the time and resources to provide information to adults with spondyloarthritis about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them. This might include details of a named person to contact, for example, a specialist rheumatology nurse. Providers have systems in place to ensure that people having flares can access care quickly in different settings.
Healthcare professionals (rheumatologists, specialist rheumatology nurses and specialist physiotherapists) discuss with adults with spondyloarthritis likely symptoms and how they can be managed, self-help options and which healthcare professionals will be involved with their care, and how and when to get in touch with them.
Commissioners (clinical commissioning groups) commission services that have the capacity and resources to provide adults with spondyloarthritis with information about their condition, which healthcare professionals will be involved with their care, and how and when to get in touch with them.
Adults with spondyloarthritis are given information about the condition, the symptoms they are likely to have and how they can cope with them, which healthcare professionals will be involved with their care, and how and when to get in touch with them.

Source guidance

Spondyloarthritis in over 16s: diagnosis and management (2017) NICE guideline NG65, recommendation 1.3.2

Definitions of terms used in this quality statement

Information about their condition
Information that will educate people with spondyloarthritis about the condition, so they understand when to get in touch with healthcare professionals for support. This information should include:
  • 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.
[Adapted from NICE’s guideline on spondyloarthritis, recommendation 1.3.2]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Referral criteria for axial spondyloarthritis

The person has low back pain that started before the age of 45 years and has lasted for longer than 3 months, with:
  • 4 or more of the additional criteria below or
  • exactly 3 of the additional criteria below and a positive HLA-B27 test.
Additional criteria are:
  • 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.

Why we made the recommendations on golimumab

NICE already recommends adalimumab, etanercept and certolizumab pegol for treating non-radiographic axial spondyloarthritis. An indirect comparison shows that golimumab provides similar overall health benefits to these drugs. The acquisition costs of golimumab are the same as or less than those of adalimumab and etanercept, and in the longer term, would be similar to those of certolizumab pegol.
Because it is has similar overall health benefits and costs to adalimumab, etanercept and certolizumab pegol, golimumab is recommended for treating non-radiographic axial spondyloarthritis in the NHS.
For more information see the committee discussion in the NICE technology appraisal guidance on golimumab for treating non-radiographic axial spondyloarthritis.
The following recommendations are from NICE technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis.
Etanercept, infliximab and adalimumab are recommended for the treatment of adults with active and progressive psoriatic arthritis when the following criteria are met.
  • The person has peripheral arthritis with 3 or more tender joints and 3 or more swollen joints, and
  • The psoriatic arthritis has not responded to adequate trials of at least 2 standard DMARDs, administered either individually or in combination.
Treatment as described above should normally be started with the least expensive drug (taking into account drug administration costs, required dose and product price per dose). This may need to be varied for individual patients because of differences in the method of administration and treatment schedules.
Etanercept, adalimumab or infliximab treatment should be discontinued in people whose psoriatic arthritis has not shown an adequate response using the PsARC at 12 weeks. An adequate response is defined as an improvement in at least 2 of the 4 PsARC criteria (1 of which has to be joint tenderness or swelling score), with no worsening in any of the 4 criteria. People whose disease has a PASI 75 response at 12 weeks but whose PsARC response does not justify continuation of treatment should be assessed by a dermatologist to determine whether continuing treatment is appropriate on the basis of skin response (see etanercept for the treatment of adults with psoriasis, infliximab for the treatment of adults with psoriasis and adalimumab for the treatment of adults with psoriasis for guidance on the use of TNF inhibitors in psoriasis).
When using the PsARC healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect a person's responses to components of the PsARC and make any adjustments they consider appropriate.
NICE has written information for the public on etanercept, infliximab and adalimumab

Why we made the recommendations on ixekizumab

Ixekizumab is a biological therapy, several of which are already recommended by NICE for treating psoriatic arthritis. Clinical trial evidence shows that ixekizumab is more effective than placebo at treating joint and skin symptoms. An indirect comparison suggests that ixekizumab is likely to be as effective at improving symptoms as some of the current treatments used in the NHS for psoriatic arthritis.
The cost-effectiveness estimates show that for some groups of people with psoriatic arthritis, ixekizumab is the most cost-effective treatment option. For other groups, the difference in health benefits between ixekizumab and the most cost-effective treatment is very small. Overall, the cost effectiveness of ixekizumab is acceptable when it is used after 2 disease-modifying anti-rheumatic drugs as the first biological therapy, or after treatment with a TNF-alpha inhibitor. Therefore, it can be recommended.
For more information see the committee discussion in the NICE technology appraisal guidance on ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs.

Glossary

(Assessment of Spondyloarthritis International Society)
(Bath ankylosing spondylitis disease activity index)
(disease-modifying antirheumatic drugs)
(non-steroidal anti-inflammatory drugs)
(outcome measures In rheumatology)
(psoriasis area and severity index)
(psoriatic arthritis response criteria)
(tumour necrosis factor)
(visual analogue scale)

Paths in this pathway

Pathway created: February 2017 Last updated: June 2018

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