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Evaluating the ASAS recommendations for early referral of axial spondyloarthritis in patients with chronic low back pain; is one parameter present sufficient for primary care practice?
  1. L van Hoeven1,2,
  2. Bart W Koes3,
  3. Johanna MW Hazes1,
  4. Angelique EAM Weel1,2
  1. 1Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands
  2. 2Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
  3. 3Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
  1. Correspondence to L van Hoeven, Department of Rheumatology, Erasmus MC, Wytemaweg 80, Rotterdam 3015 CN, The Netherlands; l.vanhoeven{at}

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New diagnostic tools and effective treatment for axial spondyloarthritis (axSpA) became available in the last decade. This has raised the need for adequate referral strategies for patients with low back pain suspected of axSpA. However, there is no agreement on which referral strategy is best. Recently, the Assessment of SpondyloArthritis international Society (ASAS) group has published recommendations for the early referral for suspected axSpA1 (box 1). Nonetheless, some critical remarks can be made regarding these recommendations.

Box 1

The Assessment of SpondyloArthritis international Society (ASAS)-endorsed recommendations for early referral of patients suspected for having axial spondyloarthritis by primary care physicians or non-rheumatologists1

  • Patients with chronic low back pain (duration ≥3 months) with back pain onset before 45 years of age should be referred to a rheumatologist if at least one of the following parameters is present:

    • Inflammatory back pain*

    • HLA-B27 positivity

    • Sacroiliitis on imaging, if available (on X-rays or MRI)†

    • Peripheral manifestations (arthritis, enthesitis and/or dactylitis)‡

    • Extra-articular manifestations (psoriasis, …

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