Axial Spondyloarthritis

Symptoms

Symptoms of axial spondyloarthritis (axSpA) can appear in many forms, which can make diagnosis difficult. It can sometimes take doctors and medical teams a long time to rule out other conditions that might share similar symptoms, or to wait to see how symptoms develop over time. In Canada, it can take almost a decade to receive a diagnosis – a barrier that researchers and clinicians are working hard to change.

Receiving a diagnosis and starting treatment early are important. People who experience symptoms for a shorter period of time typically have a better response to treatment. 

Being able to recognize symptoms early is key to seeking support from a doctor, and getting set on the path to diagnosis. 

The most common symptom of axSpA is chronic low back pain that seems to come and go, or ‘flare’ for no apparent reason. Pain and stiffness are generally worse in the morning or after prolonged periods of rest, and they improve with stretching and exercise as the day progresses. People with axSpA tend to feel better after exercise and worse after rest. AxSpA back pain generally persists for weeks or months, rather than hours or days.

Most people will experience back pain at some point in their lives. Studies show about 25% (1 in 4) of people will develop chronic back pain, and roughly 5% (1 in 20) of those cases are caused by spondyloarthritis. 

It is important to pay attention to your symptoms if you have back pain that lasts longer than two weeks. If you have not done any activities that could have caused back pain, it is best to talk to a doctor to find out what may be causing your pain. 

Back Pain

Acute back pain
Acute back pain lasts less than six weeks and typically occurs after or alongside an injury or sudden change in a chronic illness. If pain lasts longer than 12 weeks, it may have another source.

Mechanical back pain
Mechanical back pain (MBP) typically improves with rest and may feel worse with movement.  It can be caused by a physical injury or could result from another condition affecting the vertebrae (bones that make up sections of the spine), disc herniation (when the rubbery tissue between vertebrae is bulged or pushed out of place), muscle strain, or related to posture or occupational stressors. Mechanical back pain typically has a physical source and should be investigated further by your doctor or healthcare team if it lasts longer than three months.

Inflammatory back pain
Inflammatory back pain (IBP) often causes stiffness in the morning, or after a period of rest, but typically this pain improves after movement or exercise. Inflammation may be part of a flare or could be longer lasting. Inflammatory back pain often develops before the age of 40 and can improve with the help of anti-inflammatory medications. 

An estimated 300,000 people living in Canada have axSpA, while about 6.5 million people living in Canada experience chronic mechanical back pain. Separating the two is important since treatments for each type of back pain are very different.

Dactylitis
In some people, painful swelling of the entire toe or finger can occur. This is called dactylitis or ‘sausage’ digit(s).

Enthesitis
The place where a tendon or ligament attaches to bone is called an enthesis (plural: entheses). There are over 100 entheses in your body with many ligaments and tendons attaching to bones. When these areas become swollen or inflamed, it is called enthesitis. People with axSpA may also experience pain in the tendons or ligaments due to inflammation caused by enthesitis. This can be experienced in addition to painful joints.

Some of the more common spots for enthesitis are underneath or on the back of the heels (Achilles tendon, plantar fascia), on the sides of the elbows (tennis/golfer’s elbow), and on the outside of the hips (greater trochanters).

Eye Health

Uveitis
Uveitis [u-vee-i-tis] is an inflammatory condition that affects the uvea (middle layer of the eye). It can cause pain, redness, and inflammation in one or both eyes. It can also cause blurred or distorted vision and may cause permanent damage or vision loss if not treated. Typically, people with axSpA experience a form called anterior uveitis (also called iritis).

Uveitis affects about 40% of people with axSpA. It is important to monitor your symptoms and let your doctor or healthcare team know if you experience pain in or behind your eyes, have blurry vision, become light sensitive, or have other vision changes with no other known cause. Catching symptoms early is important to minimizing changes to your vision.

Fatigue
Fatigue is common among people with inflammatory arthritis. This could be related to inflammation or from years of disrupted sleep caused by pain. It can be difficult to tell what is causing fatigue, and while some people notice an improvement in their level of fatigue from treatment, others do not, even though they may have symptom relief from pain and stiffness. In these cases, fatigue may be caused by more than just disease activity.

Joint Fusion
When symptoms of axSpA go untreated, some people may develop fusion of the ligaments and rubbery discs between the vertebrae. When this happens, it may be difficult for them to bend their spine or rotate their necks. While not all people with axSpA develop fusion, people who are male are at an increased risk. Other risk factors include, elevated inflammation markers, inflammation on imaging, positive HLA-B27 gene testing, and smoking.

Skin Rashes

Psoriasis
Psoriasis is a skin condition recognized by clearly defined, raised patches of skin (called plaques) that are often red and covered with flaky skin (called scale). These patches can be very itchy but are rarely painful. In people with darker skin, plaques may be thicker, darker, and have a purplish, grey or brown colour. For people with lighter skin, the plaques may appear red or have a silvery white scale made of built-up dead skin cells.

Diagnosis

Early, accurate diagnosis of axial spondyloarthritis (axSpA) is important because the damage it causes is difficult if not impossible to reverse; however, early detection and treatment can prevent lasting damage to the spine. 

AxSpA can be difficult to diagnose since it has such a wide range of symptoms, and some people may not realize their symptoms are a sign of something more serious until they have already started to progress. In Canada, it takes an average of 9 years to receive a diagnosis.

Since some people only experience episodes, or flares of mild back pain, symptoms may go unnoticed for years. If you are concerned your symptoms are too vague or you are not sure if it is serious enough, it is always best to get checked out anyway. 

If you have symptoms of axSpA, it is important to talk to a doctor so they can help determine what might be causing your symptoms. Your doctor will also want to know what kind of back or joint pain you have been experiencing, how long you have had it, and if you have found relief from movement, or other activities.

If you have chronic back pain and history of uveitis, psoriasis, or inflammatory bowel disease (ulcerative colitis or Crohn’s disease), you should be assessed by a rheumatologist.

Using a symptom tracker can help you communicate symptoms to your doctor.

Imaging

To help make a diagnosis, your doctor will order imaging, such as x-ray or MRI. The images will help your doctor see if there are any unusual growths on your bones, or changes to your joints that may be causing your symptoms. 

Blood Test

HLA-B27
To help make a diagnosis, your doctor will likely order a blood test to check if you have a gene called HLA-B27. 

If you are positive for the HLA-B27 gene, it can be an indication that you are at higher-than-average risk for developing an autoimmune condition. If you have symptoms of axSpA, and a positive blood test for HLA-B27, it can help in making a diagnosis. Roughly 2% of individuals with this gene will develop axSpA although this increases to 30% if an individual also has chronic back pain. It is also possible to have a negative test result and still receive a diagnosis for axSpA. This test is just one tool doctors use to help make a diagnosis. 

Early intervention and treatment of axSpA is important to help prevent or slow disease progression. While diet and exercise can be helpful in managing some symptoms, some people with axSpA will need to take medication to help keep symptoms under control and prevent or reduce further damage to joints and ligaments. 

Once a diagnosis of axSpA has been confirmed, your doctor will work with you to develop a treatment plan. Sometimes this may mean trying different medications until you find something that works for you.

Medications 

The goal of treatment for axSpA is to relieve pain and stiffness so you can continue with daily activities. 

There are many different types of medications that can help relieve symptoms, but they do not all work in the same way. These medications can be very complex, so you are encouraged to ask for in-depth explanations from your healthcare team – including pharmacists, who are an excellent source of information. 

To learn more information about specific medications, visit Arthritis Society Canada’s Medication Reference Guide. 

EXPLORE: Watch the video Biologics, Biosimilars and JAK Inhibitors.

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually the first type of medication prescribed for pain and inflammation. NSAIDs do not treat the underlying cause of axSpA, but they may be helpful in relieving acute symptoms of pain and inflammation.

NSAIDs work by reducing the amount of a hormone called prostaglandin, which your body creates to respond to pain and inflammation. The most effective way to use NSAIDs for predictable forms of pain is to take your recommended dose as soon as you begin feeling pain or inflammation. This will help limit the amount of prostaglandin your body creates and maximize the medication’s ability to reduce pain and inflammation. Many people with axSpA take NSAIDs daily. The risks and benefits of long term NSAID use should be discussed with your rheumatologist.

Using NSAIDs long-term can irritate the stomach, so it is recommended to take these medications with food, and you may be given an additional medication to help protect your stomach. NSAID use can also worsen conditions such as high blood pressure and kidney disease. Your healthcare team will monitor you for these kinds of complications.

It is important to always follow the directions given to you by your doctor on how to take medications, as they will have information that is specific to you and your health needs.​​​ ​​​If NSAIDs are ineffective or cannot be used, your doctor or nurse practitioner may recommend another form of medication.

​​​Disease Modifying Anti-Rheumatic Drugs

Disease Modifying Anti-Rheumatic Drugs (DMARDs) are a class of arthritis medications that are designed to suppress and modify the immune system’s inflammation response. These medications are often taken long-term and can take weeks before their effects are felt. Since each person can have a different response to each type of DMARD, sometimes a combination of medications, known as combination therapy, is needed to be most effective at relieving symptoms and controlling the disease.

Biologics and Biosimilars

Inflammation is the body’s natural response to fighting infections or healing trauma. Diseases such as axSpA cause abnormal amounts of inflammation in joints, tendons, and bone which causes pain, swelling, and stiffness. Chronic inflammation can result in irreversible destruction of cartilage in joints, which may lead to joint deformity and loss of function. 

Biologics and biosimilars are a form of DMARD created from living cells. Biologic or biosimilar drugs work by blocking specific inflammation signals, improving pain and preventing damage to joints.

A common target for biologics is a small protein in the body called tumor necrosis factor alpha (TNF-α), which is responsible for much of the inflammation, pain, and bone deformities that can occur. Medications that target TNF-α include:

• adalimumab
• certolizumab pegol
• etanercept
• golimumab 
• infliximab

Alternative treatments to TNF-α inhibitors include interleukin-17a (IL-17a) blockers such as:

• bimekizumab 
• ixekizumab 
• secukinumab 

Less commonly, an oral medication called sulfasalazine may be used in people who cannot take NSAIDs. It is also helpful for some people with peripheral joint involvement. 

Janus Kinase (JAK) inhibitors

Janus Kinase or JAK inhibitors are another type of DMARD, belonging to a family of drugs called tsDMARDs (targeted synthetic disease-modifying anti-rheumatic drugs). These drugs block specific enzymes in the body (e.g., JAK1, JAK2, JAK3, TYK2) to reduce the body’s overactive immune response by interrupting how signals are sent throughout the cells.

Commonly used JAK inhibitors include:

• tofacitinib
• upadacitinib

Corticosteroids

Corticosteroids such as prednisone are in a class of medication that help alleviate inflammation. They are often fast-acting and very potent. Corticosteroids are sometimes prescribed during the early stages of symptom development or during a flare to help get pain and inflammation under better control before deciding on a longer-term treatment plan. Long-term use of prednisone is not recommended except in rare circumstances.

Long-term use is associated with many side effects including weight gain, diabetes, high blood pressure, cardiovascular disease, fractures, infections, cataracts, glaucoma, and adrenal insufficiency. It is important to follow directions on how to take this type of medication, and how and when to stop.

Surgery 

Those with severe, advanced r-axSpA may require surgery for badly damaged joints. Surgery usually involves replacing a joint with an artificial joint. This is called a total joint replacement, most often used for end-stage damage to the hip or knee joints. Benefits include less pain, better movement, and restored function. Spinal surgery is complex and is only used in those with severe deformity.

For more information on hip, knee or ankle replacements, please visit our comprehensive section on surgery. 

Explore forms of self-management for inflammatory arthritis, including joint protection, exercises, relaxation techniques, and eating well. 

Self-management