A 25-year-old man with ankylosing spondylitis comes to the office for reevaluation of persistent low back pain and stiffness. The patient was first seen 6 months ago with intermittent pain that responded well to naproxen. The pain has since progressed and now occurs throughout the day and is no longer relieved by naproxen. The patient is unable to fully participate in an exercise program due to his symptoms. He is a lifetime nonsmoker and does not use alcohol or illicit drugs. Erythrocyte sedimentation rate is 90 mm/hr. Which of the following is the most appropriate next step in management of this patient?
Treatment of ankylosing spondylitis | |
Nonpharmacologic |
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Initial treatment |
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Treatment failure/ |
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COX-2 = cyclooxygenase-2; NSAIDs = nonsteroidal anti-inflammatory drugs; ROM = range of motion; TNF-α = tumor necrosis factor-alpha. | |
This patient has ankylosing spondylitis (AS) with chronic back pain and stiffness associated with elevated inflammatory markers (eg, erythrocyte sedimentation rate). All patients with AS should be advised on maintaining a regular exercise program that includes postural and range-of-motion exercises; supervised physical therapy is often beneficial, especially when initiating exercise. In addition, nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, naproxen) or cyclooxygenase-2 inhibitors (eg, celecoxib) are typically very helpful and may be adequate for many patients.
The pathogenesis of AS is driven in part by inflammatory cytokines, particularly tumor necrosis factor-alpha (TNF-alpha) and IL-17. Specific large-molecule biologic inhibitors of these cytokines, including TNF-alpha inhibitors (eg, etanercept, infliximab) and IL-17 inhibitors (eg, secukinumab), are indicated for patients who have severe and persistent symptoms despite NSAID therapy.
(Choice A) When initial treatment with one NSAID fails, the condition sometimes responds to a different drug from the class. However, this patient's symptoms are progressing despite an initial good response, and trials of additional NSAIDs (eg, ibuprofen) are unlikely to be successful.
(Choice B) Most first-line, disease-modifying, antirheumatic drugs (eg, sulfasalazine, methotrexate), as commonly used in the treatment of rheumatoid arthritis (RA), have little to no benefit for spinal disease in AS, although they are occasionally used for individuals with predominantly peripheral joint symptoms.
(Choice C) Mycophenolate is most commonly used to prevent rejection in patients with allogeneic transplants. It is also prescribed for certain autoimmune disorders (eg, RA, systemic sclerosis). Although mycophenolate is occasionally used for uveitis associated with AS, it is not standard treatment for spinal manifestations.
(Choice D) Rituximab is a chimeric anti-CD20 monoclonal antibody that suppresses B-cell activity in patients with RA. However, the immune response in AS is mediated primarily by T-cell activity.
Educational objective:
The initial treatment of ankylosing spondylitis includes regular exercise and nonsteroidal anti-inflammatory drugs. Tumor necrosis factor inhibitors and IL-17 inhibitors are used in patients whose conditions do not respond to less aggressive treatment.