Clinical Commander

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rheum.axial-spondyloarthritis.core.v1

Axial spondyloarthritis

rheumatologychronicadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Manifest pointer is a PLACEHOLDER (prisma/seed/manifests/rheum.gca.chronic.v1.ts) — a dedicated rheum.axial-spondyloarthritis manifest is not yet authored; tracked in design brief Open gaps. No axSpA-specific calculator in clinical-tools-registry.ts — ASDAS-CRP / BASDAI / BASFI / BASMI disease-activity and treat-to-target are encoded in flow prose + regimen monitoring shorthand; calc.qsofa / calc.news2 used as whitelisted disposition surrogates only. RxNav RxCUIs deferred — no rxcui fields on any RegimenDrug or SettingDrugAction per task constraint; backfill + npm run research:rxnav:validate required before PRODUCTION. No problem-package folder under src/lib/tier3/problem-package/packages/ for axSpA; design brief authored under src/lib/dossiers/_briefs/.

Entry points (5)

  • symptom
    Chronic inflammatory back pain (insidious onset <45 y, >3 months) (ASAS-EULAR 2022; ASAS IBP criteria Sieper 2009)
    inflammatory_back_pain
  • symptom
    Enthesitis (Achilles/plantar fascia), dactylitis, or asymmetric lower-limb oligoarthritis (ASAS-EULAR 2022)
    peripheral_spa_features
  • history
    Acute anterior uveitis, psoriasis, or IBD with chronic back pain (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
    extra_musculoskeletal_manifestation
  • lab_abnormality
    HLA-B27 positive with chronic back pain or family history of SpA (ASAS classification criteria Rudwaleit 2009)
    hla_b27_positive_with_back_pain
  • imaging
    Sacroiliitis on pelvic radiograph (modified New York) or active inflammation on MRI SI joints (ASAS classification criteria Rudwaleit 2009)
    sacroiliitis_on_imaging

Required inputs (14)

  • age_at_symptom_onsetrequired
    demographic • used at ENTRY
    Inflammatory back pain definition requires onset <45 y; classification arm depends on age at onset (ASAS classification Rudwaleit 2009)
  • inflammatory_back_pain_featuresrequired
    symptom • used at ENTRY
    Insidious onset, >3 mo, morning stiffness >30 min, improvement with exercise not rest, night pain (2nd half), alternating buttock pain — drives pretest probability (ASAS-EULAR 2022; Sieper 2009 IBP)
  • peripheral_or_enthesitis_features
    symptom • used at CONTEXT
    Enthesitis / dactylitis / peripheral arthritis define peripheral domain; csDMARD only helps peripheral, not axial (ASAS-EULAR 2022)
  • acute_anterior_uveitisrequired
    history • used at CONTEXT
    Recurrent uveitis steers biologic choice toward monoclonal-antibody TNFi over IL-17i / etanercept; urgent ophthalmology if active (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
  • inflammatory_bowel_diseaserequired
    history • used at CONTEXT
    Active IBD contraindicates IL-17 inhibitors and favours monoclonal TNFi; gastroenterology co-management (ASAS-EULAR 2022)
  • psoriasis
    history • used at CONTEXT
    Psoriasis overlaps with psoriatic arthritis sibling and favours IL-17i / TNFi; informs differentiation pivot (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
  • cardiovascular_riskrequired
    history • used at RISK_STRATIFICATION
    JAK inhibitors carry boxed MACE/VTE warning; chronic inflammation raises ASCVD; aortitis/conduction disease screen (ASAS-EULAR 2022; ORAL Surveillance Ytterberg NEJM 2022)
  • latent_tb_and_hbv_statusrequired
    history • used at TREATMENT
    Mandatory latent TB (IGRA/TST) + HBV (HBsAg/anti-HBc) screen before any biologic or JAKi; treat latent TB before starting (ASAS-EULAR 2022)
  • osteoporosis_or_vertebral_fracture
    history • used at CONTEXT
    Paradoxical low BMD with syndesmophytes; vertebral fracture risk through ankylosed spine — DXA + spine imaging surveillance (ASAS-EULAR 2022)
  • pregnancy_or_conception_plan
    demographic • used at TREATMENT
    Certolizumab pegol minimal placental transfer — pregnancy-compatible biologic; NSAID timing relative to conception/3rd trimester (ASAS-EULAR 2022)
  • hla_b27required
    lab • used at INITIAL_WORKUP
    Anchors the ASAS clinical arm (HLA-B27 + ≥2 SpA features) and raises pretest probability (ASAS classification Rudwaleit 2009)
  • crprequired
    lab • used at INITIAL_WORKUP
    Objective inflammation; elevated CRP is an SpA feature, a poor-prognosis marker, and a component of ASDAS-CRP disease activity (ASAS-EULAR 2022)
  • esr
    lab • used at INITIAL_WORKUP
    Acute-phase reactant supporting active inflammation when CRP discordant (ASAS-EULAR 2022)
  • si_joint_imagingrequired
    imaging • used at INITIAL_WORKUP
    Pelvic radiograph (modified New York) defines radiographic AS; MRI SI joints (active osteitis/BME) defines non-radiographic axSpA — the imaging arm of ASAS classification (Rudwaleit 2009)

12-phase flow (12)

  1. 1FRAME
    Adult axial spondyloarthritis spectrum: radiographic axSpA (ankylosing spondylitis, modified New York) ↔ non-radiographic axSpA; same disease continuum, same treatment ladder (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
    advance: scope confirmed — chronic axial-predominant SpA
  2. 2ENTRY
    Recognise chronic inflammatory back pain (insidious, age <45 y, >3 mo) ± peripheral/EMM features; refer to rheumatology for classification (ASAS-EULAR 2022; ASAS IBP Sieper 2009)
    inputs: age_at_symptom_onset, inflammatory_back_pain_features
    advance: inflammatory back pain or SpA-feature entry trigger present
  3. 3CONTEXT
    Capture SpA domains and extra-musculoskeletal manifestations that drive drug choice: acute anterior uveitis, psoriasis, IBD, peripheral arthritis/enthesitis/dactylitis, family history, prior NSAID/biologic exposure, comorbid CVD/osteoporosis (ASAS-EULAR 2022)
    inputs: peripheral_or_enthesitis_features, acute_anterior_uveitis, inflammatory_bowel_disease, psoriasis, osteoporosis_or_vertebral_fracture
    advance: SpA domain + EMM + comorbidity profile captured
  4. 4RED_FLAGS
    Spinal fracture through an ankylosed/bamboo spine after low-energy trauma (high spinal-cord-injury risk — CT not plain film, immobilise); cauda equina syndrome; acute anterior uveitis (urgent same-day ophthalmology); aortitis / aortic regurgitation / high-grade AV block (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
    inputs: acute_anterior_uveitis
    actions: workup.acute_weakness
    advance: fracture/cord/uveitis/cardiac red flags screened and escalated if present
  5. 5INITIAL_WORKUP
    HLA-B27, CRP, ESR, CBC; pelvic radiograph (modified New York sacroiliitis) and/or MRI SI joints (active osteitis/BME) — the imaging vs clinical ASAS arm; baseline CMP/LFT before biologic; latent TB (IGRA) + HBV serology (ASAS-EULAR 2022; ASAS classification Rudwaleit 2009)
    inputs: hla_b27, crp, esr, si_joint_imaging
    actions: workup.joint_pain, panel.inflammation, panel.cbc, panel.metabolic
    advance: classification labs + SI imaging obtained
  6. 6BRANCHING_WORKUP
    X-ray negative but high suspicion → MRI SI joints for active inflammation (nr-axSpA); peripheral domain prominent → joint/enthesis ultrasound or MRI; suspected IBD → GI referral/endoscopy; cardiac symptoms → ECG + echo for aortitis/AV block; chronic disease → DXA + spine radiograph for vertebral fracture/syndesmophytes (ASAS-EULAR 2022)
    inputs: si_joint_imaging
    actions: workup.acute_lbp, panel.cmp
    advance: imaging/specialty branch resolved; axSpA confirmed or excluded
  7. 7DIFFERENTIAL
    Non-radiographic vs radiographic axSpA; peripheral SpA; psoriatic arthritis (axial PsA overlap); reactive arthritis; IBD-associated arthritis; mechanical/degenerative back pain; DISH (Forestier); osteitis condensans ilii; infection (Brodie/discitis); malignancy (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
    actions: workup.polyarthritis
    advance: axSpA phenotype assigned and mimics excluded
  8. 8RISK_STRATIFICATION
    Quantify disease activity with ASDAS-CRP (preferred; ≥2.1 active, ≥3.5 very high) and/or BASDAI (≥4 active); BASFI for function; poor-prognosis markers (elevated CRP, MRI inflammation, radiographic progression, hip involvement); set treat-to-target (ASDAS <2.1 / inactive ≤1.3) (ASAS-EULAR 2022 T2T)
    inputs: crp, cardiovascular_risk
    advance: disease activity scored; treat-to-target threshold set
  9. 9TREATMENT
    Cornerstone = patient education + structured exercise/physiotherapy lifelong + NSAID first-line (continuous, max-tolerated dose if active; assess GI/CV/renal) (ASAS-EULAR 2022). csDMARDs (sulfasalazine/MTX) INEFFECTIVE for axial disease — only peripheral arthritis. Active disease (ASDAS ≥2.1) despite ≥2 NSAIDs over ≥4 wk each → bDMARD: TNF inhibitor or IL-17 inhibitor (secukinumab/ixekizumab) chosen by EMM comorbidity (recurrent uveitis or active/concomitant IBD → monoclonal TNFi preferred over IL-17i and over etanercept; AVOID IL-17i in active IBD), OR JAK inhibitor (upadacitinib/tofacitinib) with boxed MACE/VTE/malignancy caution (ASAS-EULAR 2023 update; ACR/SAA/SPARTAN 2019). Switch within or across class on primary/secondary failure. NEVER use systemic glucocorticoids for axial disease — local intra-articular/entheseal injection only. Screen+treat latent TB and HBV before biologic; vaccinate (no live vaccines on biologic); manage uveitis/IBD/psoriasis collaboratively; osteoporosis/vertebral-fracture surveillance; ASCVD risk reduction; certolizumab if pregnancy/conception planned (ASAS-EULAR 2022)
    inputs: crp, acute_anterior_uveitis, inflammatory_bowel_disease, latent_tb_and_hbv_status, pregnancy_or_conception_plan
    advance: exercise + NSAID established; bDMARD/JAKi selected by EMM if active despite NSAIDs; TB/HBV cleared
  10. 10DISPOSITION
    Outpatient rheumatology-led care; inpatient/ED only for spinal fracture through ankylosed spine (spine immobilisation + neurosurgery/spine), cauda equina, severe acute uveitis needing same-day ophthalmology, or aortitis/high-grade AV block needing cardiology (ASAS-EULAR 2022)
    advance: level of care set; specialty consults secured
  11. 11MONITORING
    ASDAS-CRP (or BASDAI) + BASFI + CRP every 1–3 mo until target then every 3–6 mo (treat-to-target); NSAID GI/renal/CV surveillance; biologic/JAKi safety (CBC, LFT, lipids for JAKi, latent TB annually, HBV reactivation); periodic spinal mobility (BASMI) + radiographic progression; DXA for paradoxical osteoporosis (ASAS-EULAR 2022 T2T)
    inputs: crp
    actions: panel.inflammation, panel.cmp
    advance: sustained disease control (ASDAS <2.1) on stable regimen
  12. 12FOLLOWUP
    Lifelong rheumatology follow-up; ongoing exercise/physiotherapy; consider tapering (not abrupt stop) of bDMARD in sustained remission; smoking cessation (accelerates radiographic progression); spine/posture and fall-prevention counselling; uveitis return precautions; vaccination + cardiovascular + bone-health maintenance; hip arthroplasty/spinal osteotomy referral for advanced structural disease (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
    advance: long-term plan + multidisciplinary co-management + counselling complete