Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Treatment of peripheral spondyloarthritis

David T Yu, MD
Astrid van Tubergen, MD, PhD
Section Editor
Joachim Sieper, MD
Deputy Editor
Paul L Romain, MD


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 ankylosing spondylitis in adults" and "Diagnosis and differential diagnosis of ankylosing spondylitis and non-radiographic axial spondyloarthritis in adults" and "Clinical manifestations and diagnosis of psoriatic arthritis" and "Spondyloarthropathy in children" and "Reactive arthritis" and "Assessment and treatment of ankylosing spondylitis in adults" and "Arthritis associated with gastrointestinal disease".)


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.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Mar 24, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Rudwaleit M, van der Heijde D, Landewé R, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011; 70:25.
  2. Zochling J, Brandt J, Braun J. The current concept of spondyloarthritis with special emphasis on undifferentiated spondyloarthritis. Rheumatology (Oxford) 2005; 44:1483.
  3. Carter JD, Gérard HC, Espinoza LR, et al. Chlamydiae as etiologic agents in chronic undifferentiated spondylarthritis. Arthritis Rheum 2009; 60:1311.
  4. Van Praet L, Van den Bosch FE, Jacques P, et al. Microscopic gut inflammation in axial spondyloarthritis: a multiparametric predictive model. Ann Rheum Dis 2013; 72:414.
  5. Rohekar S, Chan J, Tse SM, et al. 2014 Update of the Canadian Rheumatology Association/Spondyloarthritis Research Consortium of Canada Treatment Recommendations for the Management of Spondyloarthritis. Part II: Specific Management Recommendations. J Rheumatol 2015; 42:665.
  6. Wendling D, Prati C. Smoking and spondyloarthritis: a bad connection. Rheumatol Int 2015; 35:1951.
  7. Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol 2016; 68:282.
  8. Mease P, Sieper J, Van den Bosch F, et al. Randomized controlled trial of adalimumab in patients with nonpsoriatic peripheral spondyloarthritis. Arthritis Rheumatol 2015; 67:914.
  9. Paramarta JE, De Rycke L, Heijda TF, et al. Efficacy and safety of adalimumab for the treatment of peripheral arthritis in spondyloarthritis patients without ankylosing spondylitis or psoriatic arthritis. Ann Rheum Dis 2013; 72:1793.
  10. Paramarta JE, Heijda TF, Baeten DL. Fast relapse upon discontinuation of tumour necrosis factor blocking therapy in patients with peripheral spondyloarthritis. Ann Rheum Dis 2013; 72:1581.
  11. Baeten D, Sieper J, Braun J, et al. Secukinumab, an Interleukin-17A Inhibitor, in Ankylosing Spondylitis. N Engl J Med 2015; 373:2534.
  12. Gossec L, Smolen JS. Treatment of psoriatic arthritis: management recommendations. Clin Exp Rheumatol 2015; 33:S73.
  13. Marzo-Ortega H, McGonagle D, O'Connor P, Emery P. Efficacy of etanercept in the treatment of the entheseal pathology in resistant spondylarthropathy: a clinical and magnetic resonance imaging study. Arthritis Rheum 2001; 44:2112.
  14. 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.
  15. Rose S, Toloza S, Bautista-Molano W, et al. Comprehensive treatment of dactylitis in psoriatic arthritis. J Rheumatol 2014; 41:2295.
  16. Turina MC, Ramiro S, Baeten DL, et al. A psychometric analysis of outcome measures in peripheral spondyloarthritis. Ann Rheum Dis 2016; 75:1302.