Rheumatologist's diagnosis of axial SpA and Elevated CRP and/or positive MRI and/or Radiogaphic sacroilitis* and Failure of standard treatment: all patients • at least 2 NSAIDs over 4 weeks (in total) patients with predominant peripheral manifestations • one local steroid injection if appropriate • normally a therapeutic trial of sulfasalazine and High disease activity: ASDAS ≥ 2.1 or BASDAI ≥ 4 and Positive rheumatologist's opinion ASAS-EULAR recommendations for the treatment of patients with axSpA with bDMARDs. Ref: van der Heijde D, Ramiro S, Landewé R, et al. Ann Rheum Dis 2017;76:978–991. Smolen JS, Schols M, Braun J, et al. Ann Rheum Dis 2018;77:3–17. 2019 ACR/SPARTAN conditionally recommend against using a target of ASDAS over a treatment strategy based on physician assessment. This recommendation is based on a low level of evidence. Ref: Ward M et al. Arthritis & Rheumatology Vol. 71, No. 10, October 2019, pp 1599–1613. Assessment of spinal mobility Bath AS Metrology Index (BASMI) The BASMI is a composite index of spinal mobility, used in clinical practice and research to measure spinal mobility and is recommended by the ASAS. The BASMI is used to obtain a baseline measurement and monitor change over time and to assess the impact of clinical interventions. The scale of the BASMI ranges from 0 to 10, where 0 is no mobility limitation and 10 is very severe limitation. • tragus-to-wall distance (TWD) - The patient is standing with the heels and back resting against the wall, with the hips and knees as straight as possible. The chin should be held at the usual carrying level. The patient is asked to put maximal effort to touch the head against the wall. The distance between the tragus and wall is measured twice in cm to the nearest 0.1 cm on the left side, and the better of two tries is recorded. The same procedure is followed for the right side. The fnal TWD is calculated by averaging the best value for the left and the right side. • modifed Schober’s test - The patient is standing erect. An imaginary line, connecting both posterior superior iliac spines, is marked. A second mark is placed 10 cm above the frst mark. The patient is asked to bend forward maximally, and the distance between the two marks is measured. The increase in cm to the nearest 0.1 cm is recorded. The modifed Schober is measured twice, and the better of two tries is recorded. • cervical rotation - The patient is sitting straight on a chair, and the chin at the normal carrying level. The assessor places a goniometer at the top of the head in line with the nose. The patient is asked to rotate the neck maximally to the left, and the assessor follows with the goniometer. The angle between the frst sagittal plane and the new plane after rotation is measured in degrees. The better of two tries is recorded. The same procedure is followed for the right side. The fnal score for cervical rotation is calculated by averaging the best values for the left and the right side and recorded in degrees. 22
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