Expert recommendations on early diagnosis and referral of axial spondyloarthritis in the Kingdom of Saudi Arabia

Axial spondyloarthritis is a chronic inflammatory disorder that primarily involves the axial skeleton (sacroiliac joints and spine), causing stiffness, severe pain and fatigue. In some patients, definitive structural damage of sacroiliac joints is visible on imaging and is known as radiographic axial spondyloarthritis. Some patients do not have a clear radiographic damage of the sacroiliac joints, and this subtype is known as non-radiographic axial spondyloarthritis. Early diagnosis is important for reducing the risk of irreversible structural damage and disability. Management of axial spondyloarthritis is challenging in Saudi Arabia because of inadequate disease knowledge and the unavailability of local guidelines. Therefore, this expert consensus is intended to provide recommendations, including the referral pathway, the definition of remission and the treat-to-target approach, to all healthcare professionals for the management of patients with axial spondyloarthritis. A Delphi technique of consensus was developed by involving an expert panel of 10 rheumatologists, 1 dermatologist and 1 general physician. The experts offered consensus-based recommendations based on a review of available scientific evidence and clinical experience for the referral, screening and management of patients with axial spondyloarthritis.

Consensus-based recommendations on the diagnosis, referral and clinical management of patients with psoriatic arthritis

Psoriatic arthritis (PsA) is a highly heterogeneous disease with complex manifestations. Limited understanding of the disease and non-availability of local guidelines pose challenges in the management of PsA in Saudi Arabia. Therefore, this expert consensus is aimed to provide recommendations on the management of patients with PsA, including referral pathway, definition of remission and treat-to-target (T2T) approach. A Delphi technique of consensus development was used involving an expert panel comprised of 10 rheumatologists, one dermatologist and one family physician. Based on the review of available published evidence and the opinions of clinical experts, key recommendations were developed. A consensus was achieved in defining the following: management guideline adaptable for Saudi Arabia, most useful screening tool, laboratory investigations, imaging tests and criteria for referring suspected PsA patients to a rheumatologist. In addition, an agreement was achieved in defining the T2T strategy and remission for the clinical management of PsA. Overall, these recommendations provide an evidence-based framework for the management of PsA patients in Saudi Arabia.

AB0566 CONSENSUS-BASED RECOMMENDATIONS FOR THE MANAGEMENT OF PSORIATIC ARTHRITIS IN THE KINGDOM OF SAUDI ARABIA

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory condition associated with psoriasis. The common clinical features of PsA include peripheral arthritis, dactylitis, enthesitis, spondylitis, skin and nail disease1. Considering the heterogeneous course of disease and the different patient characteristics, there is a need to standardize management of PsA patients. At present, no established guidelines are available on PsA care pathway in Saudi Arabia.

Objectives:

To provide consensus-based guidance to all Saudi health care providers (HCPs) on the management of PsA patients including referral pathway, definition of remission and treat-to-target approach.

Methods:

A Delphi technique was used to understand PsA patient care pathway. In first step, a targeted literature review was conducted and a survey questionnaire including 16 questions was developed to explore PsA patient journey. In second step, this questionnaire was submitted to 127 HCPs and 33 of them provided their response. In third step, a panel of 12 experts including 10 rheumatologists, 1 dermatologist and 1 general physician reviewed the available evidence along with survey results to align on final recommendations.

Results:

The most common management guidelines recommended for PsA were European League against Rheumatism (EULAR, 100% agreed) and American College of Rheumatology (ACR, 100% agreed). Psoriasis Epidemiology Screening Tool (PEST) was recommended by 67% of experts as validated screening tool for PsA in dermatology clinic. The laboratory investigations included were C-reactive protein (CRP, 100%), erythrocyte sedimentation rate (ESR, 100%), complete blood count (92%), urea and creatinine (92%), liver function (92%), rheumatoid factor (56%) and X-ray of affected joints (75%). For patients with additional symptoms of back pain, X-ray of sacroiliac joints and human leukocyte antigen B27 (HLA-B27) test to be included. Only rheumatologists should recommend a magnetic resonance imaging based on the individual clinical picture. The agreement criteria for HCPs for referring patient to a rheumatologist were presence of psoriasis (100%) and one of the following features: dactylitis [100%], joint pain [100%], arthritis [100%], nail dystrophy [91%]. Patient with active arthritis should be referred to rheumatologist within 4 weeks. The referral pathway agreed by the experts for PsA patients is presented in Figure 1. Majority of experts (57%) defined clinical remission as absence of disease activity in all facets of disease assessed using the disease activity in psoriatic arthritis (DAPSA) or minimal disease activity (MDA) index. For treat-to-target, 71% of experts agreed on EULAR recommendations2. For remission and treat-to-target, experts identified a need for more clear definition.

Conclusion:

This expert consensus aimed to provide guidance to Saudi HCPs on standardizing diagnosis and care of PsA patients. Most experts recommended PEST as validated screening tool for PsA along with laboratory investigations such as CRP, ESR, X-ray, etc. Referral to a rheumatologist should be considered for patient with presence of psoriasis and one of the other defining features for PsA. There is a need for more clear definition of remission and treat-to-target.

References:

[1]Ogdie A, et al. Rheum Dis Clin North Am. 2015;41(4):545–568.

[2]Gossec L, et al. Ann Rheum Dis. 2020;79:700–712.

Figure 1.

Referral pathway for psoriatic arthritis patients CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; CBC: Complete blood count; HLA-B27: Human leukocyte antigen B27; PEST: Psoriasis Epidemiology Screening Tool

Acknowledgements:

This project was supported by Novartis Saudi Ltd., Saudi Arabia and the Saudi Society for Rheumatology. We would also like to thank Dr. Xenofon Baraliakos for his support.

Disclosure of Interests:

Hanan Alrayes: None declared., Mansour Alazmi Speakers bureau: Pfizer, Abbvie, Khaled Alderaan: None declared., Mushabab Alghamdi: None declared., Nayef Alghanim: None declared., Ahmed Alhazmi: None declared., Nadeer Alkhadhrawi: None declared., Mohammad Almohideb Speakers bureau: Novartis, Abbvie, Celgene, Lilly, Jansen and Sanofi, Grant/research support from: Sanofi and Abbvie, Suzan Attar Speakers bureau: Lectures in symposium about different diseases in rheumatology and management, Grant/research support from: Research in recruiting patient, Zyad ahmed Alzahrani Speakers bureau: Pfizer, Novartis, MSD, Janssen, Abbvie, Lilly, Consultant of: Pfizer, Novartis, MSD, Janssen, Abbvie, Lilly, Mohamed Bedaiwi: None declared., Nancy Zakaria Employee of: Novartis, Hussein Halabi: None declared.