Dear Editor,
Axial spondyloarthritis (SpA) is a debilitating yet often overlooked disease affecting many young people in Pakistan. Typically beginning in early adulthood, SpA is a chronic inflammatory condition targeting the spine and sacroiliac joints. Without timely diagnosis and treatment, it often progresses and can lead to severe disability (1, 2). Unfortunately, awareness of SpA is low among both the general public and healthcare providers. Chronic back pain in young adults is frequently misattributed to mechanical or lifestyle factors, resulting in years of misdiagnosis (1, 3, 4). This delay leads to serious consequences: Spinal fusion, reduced mobility, poor quality of life, and growing financial strain on families. In developed countries, early detection is aided by the Assessment of SpondyloArthritis International Society (ASAS) criteria, using tools like MRI and other clinical indicators (1, 3, 5). In Pakistan, however, early diagnosis is rare due to poor access to rheumatology care, high imaging costs, limited musculoskeletal training in primary care, and the general neglect of rheumatology as a specialty (6, 7).
The lack of data on SpA incidence in Pakistan hampers effective resource allocation and health policy planning. In a semi-urban community of Lahore, Pakistan, 6.7% of individuals reported inflammatory back pain according to ASAS criteria, with rheumatologist-confirmed cases at 2.9% (8). The prevalence of radiographic SpA was found to be 1% (8). Further locally conducted research is urgently needed to assess HLA-B27 prevalence, measure disease burden, and understand sociocultural barriers to timely diagnosis and care (7, 9). Even though over the past two decades, the diagnosis and treatment of chronic rheumatic illnesses, including axial SpA, have significantly advanced, disparities persist in developing countries such as Pakistan (10). A better understanding of the immunopathogenesis of SpA has led to new therapies that greatly improve symptoms and quality of life. Current treatments include conservative measures such as physical therapy and NSAIDs, in addition to biologic therapy consisting of TNF inhibitors, IL-17 inhibitors, or JAK inhibitors (11, 12). Recent studies have also demonstrated the role of non-pharmacologic measures such as MLS laser and vibration therapy in the management of chronic low back pain (13, 14). However, biologic therapies, though effective, remain inaccessible to many due to high costs and lack of insurance coverage, especially in resource-limited countries including Pakistan (1, 9). Public hospitals often lack rheumatology services, forcing patients to seek expensive private care or forgo treatment altogether (7, 9).
To address these issues, general practitioners must be trained to recognize the early signs of inflammatory back pain, which are often missed in routine clinical settings. Public awareness campaigns are also essential to reduce stigma, correct misconceptions, and encourage timely consultations. Expanding rheumatology services across Pakistan and increasing government support for biologic therapies and diagnostic tools would significantly enhance patient care. Although SpA is a chronic condition, it can be effectively managed with early intervention. We urge the medical community and health authorities to recognize the growing burden of SpA and take immediate steps to ensure timely diagnosis and access to effective treatment.
In addition to these broader recommendations, we propose two specific and actionable measures. First, a multi-center epidemiological study should be conducted across major hospitals and academic institutions in Pakistan to establish the prevalence of axial SpA, assess the average diagnostic delay, and determine HLA-B27 positivity rates. This data will provide a critical foundation for evidence-based policymaking and resource allocation. Second, a pilot project should be launched in a selected district to train primary care physicians in identifying inflammatory back pain and the early clinical features of axial SpA. The outcomes of this training should be systematically evaluated, particularly its impact on referral patterns and diagnostic timelines, with the aim of scaling the program nationally if successful. Together, these initiatives offer a practical, evidence-based roadmap for improving early diagnosis and long-term management of axial SpA in Pakistan.
