Treatment of peripheral spondyloarthritis
- David T Yu, MD
David T Yu, MD
- Emeritus Professor
- University of California Los Angeles
- Astrid van Tubergen, MD, PhD
Astrid van Tubergen, MD, PhD
- Maastricht University Medical Center
Peripheral spondyloarthritis (SpA) is the term used to describe patients with features of SpA whose symptoms and findings are predominantly or entirely peripheral rather than axial; these features include arthritis, which is predominantly of the lower limbs and/or asymmetric; enthesitis; and dactylitis. Patients included in this category, who have these findings in common, include those with psoriatic arthritis (PsA), reactive arthritis, SpA related to inflammatory bowel disease (IBD), and the subset of patients with such manifestations who do not meet established definitions for these forms of SpA. Patients with ankylosing spondylitis and non-radiographic axial SpA are not included within the peripheral SpA category, even if peripheral manifestations of musculoskeletal involvement are also present [1,2].
A clear distinction between the clinically defined subsets of patients with peripheral SpA is often lacking, other than for those with PsA. As examples, in a considerable number of patients skin manifestations of psoriasis do not occur until after the manifestation of rheumatic symptoms; preceding infections may be clinically asymptomatic, as an example, with Chlamydia; and IBD can also be asymptomatic when patients present with musculoskeletal symptoms [3,4].
The treatment of peripheral SpA in adults will be presented here. An overview of the clinical manifestations and diagnosis of peripheral SpA; the classification of SpA; and the clinical manifestations, diagnosis, and treatment of ankylosing spondylitis, non-radiographic axial SpA, PsA, reactive arthritis, arthritis associated with IBD, and SpA in children are discussed in more detail separately. (See "Clinical manifestations and diagnosis of peripheral spondyloarthritis in adults" and "Overview of the clinical manifestations and classification of spondyloarthritis" and "Clinical manifestations of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults" and "Diagnosis and differential diagnosis of axial spondyloarthritis (ankylosing spondylitis and non-radiographic axial spondyloarthritis) in adults" and "Clinical manifestations and diagnosis of psoriatic arthritis" and "Spondyloarthritis in children" and "Reactive arthritis" and "Assessment and treatment of ankylosing spondylitis in adults" and "Clinical manifestations and diagnosis of arthritis associated with inflammatory bowel disease and other gastrointestinal diseases".)
The primary treatment goal in patients with peripheral spondyloarthritis (SpA) is to optimize short- and long-term health-related quality of life, which is accomplished through use of a combination of nonpharmacologic and pharmacologic treatments to control inflammation, prevent structural damage to the joints, and preserve function and social participation. (See 'Nonpharmacologic and preventive therapies' below and 'Pharmacotherapy' below and 'Monitoring' below.)
Most patients benefit from care by an expert in rheumatologic disease, such as a rheumatologist, and care should be coordinated with appropriate specialists depending upon the clinical features, such as a dermatologist for psoriasis, gastroenterologist for inflammatory bowel disease (IBD), or an expert in uveitis.
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- Orbai AM, Weitz J, Siegel EL, et al. Systematic review of treatment effectiveness and outcome measures for enthesitis in psoriatic arthritis. J Rheumatol 2014; 41:2290.
- Rose S, Toloza S, Bautista-Molano W, et al. Comprehensive treatment of dactylitis in psoriatic arthritis. J Rheumatol 2014; 41:2295.
- Turina MC, Ramiro S, Baeten DL, et al. A psychometric analysis of outcome measures in peripheral spondyloarthritis. Ann Rheum Dis 2016; 75:1302.
- GENERAL PRINCIPLES
- NONPHARMACOLOGIC AND PREVENTIVE THERAPIES
- - Initial therapy
- - Resistant to initial therapy
- - Resistant to nonbiologic DMARD
- Axial manifestations
- Extraarticular manifestations
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS