Vikas Majithia, MD, and Abhijeet Danve, MD, on Diagnosing AxSpA: Part 3

In the third and final part of their podcast, Drs Majithia and Danve talk about tools now available to help clinicians confirm a diagnosis of axial spondyloarthritis.

Vikas Majithia, MD, is chair of the Division of Rheumatology and a senior associate consultant in the Department of Medicine at Mayo Clinic-Florida in Jacksonville. Abhijeet Danve, MBBS, MD, is an associate professor of rheumatology and director of the Spondyloarthritis Program at Yale University.

TRANSCRIPT:

Thanks for joining us for part 3 of this podcast with doctors Vikas Majithia and Abhijeet Danve, who are discussing diagnosing axial spondyloarthritis. Today, they'll be talking about some tools that can be helpful to the clinician in confirming the diagnosis.

Vikas Majithia:

So one of the last things that I wanted to cover in this podcast is apparently there are a number of factors for delay in diagnosis. What can we do at this point and what do you see in the future to be done to mitigate this delay?

Abhijeet Danve:

I think that's a very important area. Diagnostic delay has been a challenging aspect in patients with axial SpA. Commonly, the delay in diagnosis ranges from 6 years to 14 years depending on which study you're looking at. The diagnostic delay is worse in women as compared to men. And there are several reasons for delay in diagnosis of this condition. Some of them we already covered, like lack of objective clinical findings in early disease, lack of confirmatory lab tests, poor sensitivity of x-ray of the sacroiliac joints. This is a slowly progressive condition, so you may see a patient at earlier stage and do not realize that they are developing and they may not come back to you, so diagnosis may be even missed. The back pain is so common in general population, 20 to 25% of the general population has chronic back pain. And there are very few thousand rheumatologists in United States. So one rheumatologist cannot really see all the back pain patients.

So what we need is we need our nonrheumatology colleagues to send the patients, to refer the patients with suspected axial SpA to us in a timely manner so that we can reduce this diagnostic delay. Also, when a patient with chronic back pain is seen by either primary care physician or chiropractor or spine surgeon, they usually get x-ray of the lumbar spine or MRI of the lumbar spine, and both of these imaging tests do not give us adequate information about what's going on in the sacroiliac joints. And these are some reasons because of which the diagnosis is delayed.

Other things like having low awareness about this condition among the primary care providers, even the rheumatology colleagues are not as enthusiastic about seeing patients with chronic low back pain and lack of referral. So lack of referral of suspected patients through rheumatology is one of the most actionable, so to say, factor that we can all work on to improve the early diagnosis of axial SpA.

Vikas Majithia:

Thank you, Dr. Danve. That, again, is very helpful to know. One of the last things I wanted to ask was are there any tools that can be used to help improve the diagnostic delay?

Abhijeet Danve:

Yes, Vikas. A lot of work is being done in this area. The previous research studies mainly come out of Europe. So there's one strategy called Berlin Strategy where if there is a patient with chronic back pain whose back pain started before age of 45; if they have either inflammatory back pain or sacroiliitis on any imaging test or they have positive B27, if these patients are referred to rheumatologists, 1 in 3 such patients will turn out to have axial SpA. So Berlin Strategy was used in one of the studies done in United States and it did yield excellent results, about 30 to 40% patients did have axial SpA. And ASIS, that is Axial Spondyloarthritis International Society, came up with referral recommendations a few years ago where they have several spondyloarthritis features that we covered in this podcast are included. And if the patient has chronic back pain for more than 3 months, that started at younger age, then if they have one of these, then they could be referred.

Sensitivities, as you may realize is high, but specificity is not as high. And to improvise on that, at Yale, we have developed a screening tool that we call A-tool, axial spondyloarthritis tool, which at this time, it's in research phase and we have enrolled about 100 patients and we think about 30% of the patients have axial SpA out of 100. So it's pretty good. It's quite comparable to the Berlin Strategy. The advantage in our tool is it does not have lab tests, does not have imaging. It's all clinical questions. So we have a 3-question prescreen and if the patient fulfills the prescreen, they're handed out an 8-question questionnaire, that's A-tool. And if they have 3 out of 8 positive answers, these patients should be referred to rheumatology for further evaluation.

Another effort that we are undertaking on behalf of SPARTAN, where you are part of this endeavor, as you know, is SPARTAN Referral Recommendation Project, where we as experts in axial SpA in the United States, Canada, and Mexico, are developing referral recommendations, something similar to that of ASIS referral recommendations. But we think it would be more appropriate for the US healthcare and the North American healthcare, more suited for North American healthcare.

Vikas Majithia:

Again, that was very helpful and insightful. Thank you so much, Dr. Danve, for joining us today.

Abhijeet Danve:

Thank you very much, Vikas.