Axial spondyloarthritis
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- NSAIDs and regular exercise or physiotherapy are the foundation of treatment and help most people.
- If a biologic medicine is needed, TNF inhibitors and IL-17 inhibitors are both good first choices.
- Treatment is guided by how you feel and your symptom scores, not by chasing one strict target number.
- Related eye, gut, and skin conditions can change which medicine is best, so tell your team about them.
- Staying active protects spinal movement. Avoid spinal manipulation if your spine is fused.
Understanding this condition
What it is
axSpA is long-term inflammatory arthritis of the spine and the sacroiliac joints (where the spine meets the pelvis). When damage is visible on an X-ray, it is often called ankylosing spondylitis; when it is not yet visible on X-ray but inflammation is present, it is called non-radiographic axSpA. Both are part of the same condition.
Symptoms
The main symptom is inflammatory back pain: a dull ache and stiffness low in the back and buttocks that is worse with rest and in the early morning, lasts more than 30 minutes, can wake you in the second half of the night, and improves with movement. Some people also get pain where tendons attach (such as the heel), swelling in an arm or leg joint, a swollen finger or toe, or tiredness.
Who gets it
axSpA usually begins in the teens, twenties, or thirties, before age 45. It affects both men and women. There is often a family history, and a gene called HLA-B27 is common in people with the condition, although many people with the gene never develop it. It affects roughly 1 in 200 to 1 in 1000 adults.
How it is diagnosed
Diagnosis uses your history and examination, blood tests (including inflammation markers and sometimes the HLA-B27 gene), and imaging. For adults, an X-ray of the pelvis (the sacroiliac joints) is usually the first imaging test. If that is not clear, an MRI without contrast can show inflammation earlier. There is no single test, so it can take time. Diagnosis has often been delayed, historically by an average of about 8 to 11 years from the first symptoms, which is part of why getting the right imaging and referral matters.
When diagnosis takes time, and being believed
For many people, getting a diagnosis of axSpA takes a long time, sometimes years, and along the way it is common to feel that your symptoms were not taken seriously. If that has been your experience, you are not alone, and it does not mean the pain was not real. Back pain is very common, and the inflammatory kind can be hard to spot early, especially when an X-ray looks normal. Keeping a clear record of your symptoms, and describing the pattern rather than only the worst day, helps your team get the picture and helps you be heard. You deserve to be believed and followed until things are clear.
What to expect over time
Many people do well with treatment and stay active and working. Some people develop more spinal stiffness or fusion over years, which is why staying active and treating inflammation matter. Related conditions, such as eye inflammation, can come and go.
Living with and treating it
Goals of treatment
The goals are to control pain and stiffness, keep the spine and joints moving, protect your function and ability to work, and treat any related conditions. Your team measures how active the disease is at visits, usually with a symptom score and blood tests.
Treatment options
Treatment combines regular exercise or physiotherapy with medicines. NSAIDs come first. If they are not enough, biologic medicines (TNF inhibitors or IL-17 inhibitors) or a JAK inhibitor tablet can calm inflammation. Steroid tablets are avoided, although a steroid injection into a single joint is sometimes used. See the treatment ladder below.
Tests and monitoring
Your team checks how you are doing at visits with a symptom score (such as ASDAS or BASDAI) and blood tests for inflammation. Repeat spine X-rays are not done on a fixed schedule. If it is unclear whether the disease is active while you are on a biologic, an MRI can help.
Flares
Flares are times when pain and stiffness get worse. During a flare, regular NSAIDs and keeping up gentle movement often help. Tell your team if flares are frequent or severe, or if you get new eye, gut, or skin symptoms, so treatment can be adjusted.
Living well
Regular exercise is one of the most helpful things you can do: it protects movement and eases stiffness. Physiotherapy, stretching, aerobic and aquatic exercise, and good posture all help. Not smoking, keeping a healthy weight, looking after your bones, and having your heart risk checked are also important. One safety point matters: spinal manipulation, such as a forceful (high-velocity) chiropractic or physiotherapy adjustment, is strongly recommended against in axial spondyloarthritis. The spine can be stiffer and the bone weaker than it looks, so manipulation carries a real risk of fracture, and that risk is highest if your spine has fused or your bones have thinned (osteoporosis). Tell any hands-on therapist that you have axial spondyloarthritis.
Quitting smokingWhy it matters for arthritis, what helps, and free Ontario programs→Exercise programme: posture, mobility, strengthA 3-part home programme, with links to the NASS Back to Action programme→Related conditions
axSpA is linked with a few other conditions: eye inflammation (uveitis, which causes a painful red eye and needs prompt care), inflammatory bowel disease, and psoriasis. Your team screens for these by asking about symptoms and works with an eye doctor, a gut specialist, or a skin doctor when needed. Bone thinning and heart risk are also watched.
What to expect at your appointment
At a first rheumatology visit, expect questions about your back-pain pattern, morning stiffness, family history, and any eye, gut, or skin symptoms; an examination of your spine, posture, and joints; blood tests; and imaging of the sacroiliac joints. Bring a list of your symptoms, when they started, what helps, and your medicines. It is a good time to ask about exercise and what to watch for.
The aim is to bring the disease to a quiet, low-activity state and keep symptoms and stiffness under control, checked at each visit. For axSpA, treatment is guided by how you feel and your scores rather than by chasing a single strict number.
BASDAI: track your disease activityAnswer 6 quick questions, see your score, save it, and print it for your visit→BASFI: track your physical function10 quick questions on everyday activities, save your result and print it for your visit→How treatment is stepped up
- 1
First step
Start with anti-inflammatory painkillers (NSAIDs) taken regularly during flares, plus a regular exercise or physiotherapy program to keep the spine moving. This is the foundation for most people.
- 2
If NSAIDs are not enough
If NSAIDs and exercise are not enough, a biologic medicine is usually next. Two groups, TNF inhibitors and IL-17 inhibitors, work well and are considered equally good first choices. Your team helps pick based on any related eye, gut, or skin conditions.
- 3
If the first biologic does not work
If a biologic is not working, the next options are a different medicine that works in a new way, or a JAK inhibitor, a tablet that also calms inflammation. If two options in a row have not worked, your team looks again at the diagnosis and other reasons before changing.
- 4
Peripheral or resistant disease
If the arm-and-leg joints or a related condition stay active, your team may add another medicine or combine treatments, chosen for your situation.
Medication guides
Plain-language guides to the medicines used for this condition. Each has a patient and a clinician view.
Living well, beyond the diagnosis
The whole-person side of living with a rheumatic disease, the parts patients tell us matter most. These guides apply across conditions.
When to get medical help
- A sudden painful red eye, blurred vision, or sensitivity to light. This can be uveitis and needs same-day eye assessment.
- A single joint that is very painful, hot, and swollen, especially with a fever, which can be a joint infection and needs urgent care.
- New leg weakness or numbness, loss of bladder or bowel control, or severe back or neck pain after a fall or injury, especially if your spine is stiff or fused. This needs emergency assessment for a possible spinal fracture.
- A fever, night sweats, or feeling very unwell while taking medicines that lower the immune system.
- New or worsening tummy pain, ongoing diarrhoea, or blood in the stool, which can point to inflammatory bowel disease.