ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis


There is still a substantial gap of 5–8 years between the onset of symptoms and the diagnosis of axial spondyloarthritis (axSpA). One of the major reasons for such a delay is a late referral of patients to a rheumatologist by general practitioners and other physicians encountering patients with back pain. This late referral can be caused by the referring doctor and/or by the patient. While several referral strategies have been proposed and tested, a universally accepted referral strategy is still lacking.


The aim of this project was to develop a consensual recommendation under the auspices of ASAS for early referral of patients with a suspicion of axial spondyloarthritis by non-rheumatologists.

Methodology: The development of a referral recommendation consisted of four phases: (1) systematic literature review, (2) the first Delphi round aiming at identification of unmet needs and development of a candidate list of referral parameters, (3) the second Delphi round aiming at identification of the most useful combination of referral parameters and (4) final discussion and formal endorsement by ASAS membership.


The following consensus on a referral recommendation was achieved as a result of the Delphi processes and final voting:

Patients with chronic back pain (duration3 months) with back pain onset before 45 years of age should be referred to a rheumatologist if at least one of the following parameters is present:

  • Inflammatory back pain*
  • Human leucocyte antigen-B27 positivity
  • Sacroiliitis on imaging, if available (on X-rays or MRI)†
  • Peripheral manifestations (in particular arthritis, enthesitis and/or dactylitis)‡
  • Extra-articular manifestation (psoriasis, inflammatory bowel disease and/or uveitis)‡
  • Positive family history for spondyloarthritis‡
  • Good response to non-steroidal anti-inflammatory drugs‡
  • Elevated acute phase reactants§


*Any set of criteria, preferably ASAS definition of inflammatory back pain: at least four out of five parameters present: (1) age at onset ≤40 years; (2) insidious onset; (3) improvement with exercise; (4) no improvement with rest; and (5) pain at night (with improvement upon getting up).

†Only if imaging available, not recommended as a routine screening parameter.

‡According to the definition applied in the classification criteria for axial spondyloarthritis:

Arthritis: past or present active synovitis diagnosed by a physician.

Enthesitis (heel): past or present spontaneous pain or tenderness at examination of the site of the insertion of the Achilles tendon or plantar fascia at the calcaneus.

Dactylitis: past or present dactylitis, diagnosed by a physician.

Extra-articular manifestation: past or present psoriasis, inflammatory bowel disease and/or uveitis anterior, confirmed by a physician.

Good response to non-steroidal anti-inflammatory drugs (NSAIDs): 24–48 h after a full dose of a NSAID the back pain is not present any more or is much better.

Family history of SpA: presence in first-degree (mother, father, sisters, brothers, children) or second-degree (maternal and paternal grandparents, aunts, uncles, nieces and nephews) relatives of any of the following: (1) ankylosing spondylitis; (2) psoriasis; (3) acute uveitis; (4) reactive arthritis; and (5) inflammatory bowel disease.

§C-reactive protein serum concentration or erythrocyte sedimentation rate above upper normal limit after exclusion of other causes for elevation.


Conclusions: A consensual ASAS-endorsed referral recommendation for patients suspected of having axial spondyloarthritis was developed as a flexible and universal strategy to be used in clinical practice by primary care physicians or non-rheumatology specialists. The practical value of this strategy applied in different settings should be determined in future studies.


Timelines of the project: 2013-2015


Project Team

PI: Joachim Sieper, Désirée van der Heijde

Steering committee:

Robert Landewé, Désirée van der Heijde, Denis Poddubnyy, Joachim Sieper, Astrid van Tubergen



1.         Poddubnyy D, van Tubergen A, Landewe R, Sieper J, van der Heijde D, Assessment of SpondyloArthritis international S. Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis. Ann Rheum Dis. 2015 Aug; 74(8):1483-1487.