Non-Radiographic Axial SpA: X-Rays, Referral, and Biologics with Dr. Iqra Aftab

In this episode of MD Newsline, Dr. Iqra Aftab, a double board-certified rheumatologist and internal medicine physician, offers a practical guide to recognizing, diagnosing, and managing axial spondyloarthritis (axial SpA), with a particular focus on non-radiographic disease. She explains why axial SpA can be overlooked in younger patients with persistent back pain and how clinicians can recognize inflammatory patterns even when conventional imaging appears normal. Dr. Aftab walks through the spondyloarthritis spectrum, distinguishing radiographic axial SpA from non-radiographic axial SpA and emphasizing that the absence of joint damage on X-rays does not mean the disease is mild or insignificant. She highlights clinical clues such as morning stiffness, improvement with exercise and anti-inflammatories, and younger age, while also discussing extra-articular manifestations including uveitis, psoriasis, and inflammatory bowel disease. The conversation also explores the appropriate role of X-rays and MRI, the distinction between classification and diagnostic criteria, treatment escalation from NSAIDs to biologic and targeted therapies, and how extra-articular disease can influence treatment selection. Dr. Aftab addresses fatigue, functional impairment, lifestyle management, multidisciplinary care, and the importance of early rheumatology referral to reduce diagnostic delays. Episode Highlights: Recognizing Inflammatory Back Pain: Dr. Aftab explains the key features that can distinguish inflammatory from mechanical back pain, including morning stiffness, improvement with exercise and anti-inflammatories, and younger age. Understanding Non-Radiographic Axial SpA: A normal X-ray does not rule out axial SpA. Dr. Aftab emphasizes that non-radiographic disease can still cause significant pain, disability, and reduced quality of life. Recognizing Extra-Articular Manifestations: Uveitis, psoriasis, and inflammatory bowel disease can provide important clues to an underlying spondyloarthritis diagnosis. Choosing Imaging and Treatment: The discussion covers when to move from X-rays to MRI and when to escalate from NSAIDs to biologic or targeted therapies. Matching Therapy to the Patient: Dr. Aftab explains how extra-articular disease, treatment risks, patient preferences, and practical considerations can influence biologic selection and treatment changes. Addressing Fatigue and Daily Function: Fatigue may stem from active inflammation or other factors, while assessing work, family life, and daily activities can reveal the true impact of disease. Knowing When to Refer: Persistent back pain with inflammatory features in a younger patient should prompt rheumatology referral, even when X-rays are normal or the diagnostic workup is incomplete. Key Takeaway: Dr. Aftab emphasizes that a normal X-ray does not rule out non-radiographic axial SpA. Recognizing inflammatory back pain, considering appropriate imaging, connecting extra-articular symptoms, and referring patients early can help reduce diagnostic delays and support timely treatment. Resources: Website: https://mdnewsline.com/ Newsletter: https://mdnewsline.com/subscribe/