Challenges in diagnosing and monitoring radiographic and non-radiographic axial spondyloarthritis in daily clinical practice

Abstract Introduction/objectives Axial spondyloarthritis (axSpA) is a heterogeneous disease with variable clinical features changing over the disease course, making diagnosis and monitoring challenging. Large progress has been made in classification development, imaging, disease-activity assessment. However, there is limited insight in how these developments are addressed in daily clinical practice. Therefore, our study aim was to gain better insight into diagnosis, monitoring and treatment and to explore if non-radiographic (nr-)axSpA is addressed differently from radiographic (r-)axSpA. Methods A multiple-choice survey on diagnosis, monitoring, and treatment of axSpA was conducted in semi-structured, face-to-face interviews with 51 Dutch rheumatologists, representing a range of geographical locations, hospital types, and axSpA expertise. Results Of all participating rheumatologists, 78% worked in secondary referral centers, reflecting Dutch rheumatology practice. 52% felt insufficiently skilled to independently assess MRI sacroiliitis. Diagnostic uncertainty was higher for nr-axSpA (23%) than r-axSpA (10%). ASAS classification criteria were used to diagnose nr- and r-axSpA by 54% and 36% of rheumatologists. For monitoring disease activity, ASDAS was always or never used by 28% and 26% of rheumatologists. In treatment decisions concerning biological DMARDs, the level of pain was considered equally important as disease activity scores (ASDAS, BASDAI). Most rheumatologists (60%) did not use ASDAS or BASDAI cut-off scores or change to evaluate biological DMARDs’ effectiveness. Conclusions This study reveals that Dutch rheumatologists experienced difficulties in diagnosing axSpA in one out of four patients. ASAS classification criteria were often used for support, particularly in diagnosing nr-axSpA. The use of disease-activity assessments during monitoring was limited. Key Points • Diagnostic uncertainty remains common in daily practice, particularly for non-radiographic axial spondyloarthritis. • Although ASAS classification criteria were developed for research purposes, they are also used to support diagnosis. • ASDAS is used inconsistently to monitor disease activity and many rheumatologists seem to base treatment decisions on reported pain level. • There seems to be a gap between axial spondyloarthritis international management recommendations and routine rheumatology care.