What is the initial treatment for spondyloarthropathy of the spine?

Initial Treatment for Spondyloarthropathy of the Spine

NSAIDs should be used as first-line drug treatment for patients suffering from pain and stiffness in spondyloarthropathy of the spine, up to the maximum dose, taking risks and benefits into account. 1

Treatment Algorithm for Axial Spondyloarthritis

First-Line Treatment

1. NSAIDs

   • Use up to maximum dose if needed
   • Consider continuous use if patient responds well and remains symptomatic
   • Monitor for gastrointestinal, renal, and cardiovascular side effects
   • No specific NSAID is preferred over others

2. Non-Pharmacological Interventions (to be used concurrently)

   • Physical therapy with supervised exercise program
   • Patient education about the condition
   • Regular exercise regimen
   • Smoking cessation

Second-Line Treatment (if inadequate response to NSAIDs)

• Biological DMARDs (bDMARDs)
  • TNF inhibitors (e.g., etanercept, adalimumab, infliximab)
  • IL-17 inhibitors (e.g., secukinumab, ixekizumab)

Evidence-Based Recommendations

NSAIDs

The 2016 ASAS-EULAR management recommendations strongly support NSAIDs as first-line therapy, stating: "Patients suffering from pain and stiffness should use an NSAID as first-line drug treatment up to the maximum dose, taking risks and benefits into account." 1

NSAIDs are highly effective against the major symptoms of axial spondyloarthritis (pain and stiffness) and may have disease-modifying properties including retarding progression of structural damage in the spine 2.

Physical Therapy

Physical therapy is strongly recommended alongside pharmacological treatment. The ACR/SAA/SPARTAN guidelines state: "We strongly recommend treatment with physical therapy over no treatment with physical therapy." 1

Supervised combined exercises and neuromuscular training have shown significant reduction in disease activity, improved physical function, and enhanced spinal mobility compared to standard care 3.

Important Considerations

Disease Monitoring

• Regular assessment using validated disease activity measures is recommended
• Monitor CRP/ESR at regular intervals
• The frequency of monitoring should be individualized based on symptoms, severity, and treatment 1

Medications to Avoid

• Conventional synthetic DMARDs: "Patients with purely axial disease should normally not be treated with csDMARDs" 1
• Systemic glucocorticoids: Long-term treatment with systemic glucocorticoids is not recommended for patients with axial disease 1
• Spinal manipulation: Strongly recommended against in patients with spinal fusion or advanced spinal osteoporosis due to risk of spine fractures, spinal cord injury, and paraplegia 1

Special Considerations

Advanced Disease

• For patients with advanced hip arthritis, total hip arthroplasty is strongly recommended if there is refractory pain or disability with radiographic evidence of structural damage 1
• Spinal corrective osteotomy may be considered in specialized centers for patients with severe disabling deformity 1

Bone Health

• Screening for osteoporosis with DXA scan is recommended due to increased risk of vertebral fractures in patients with axial spondyloarthritis 1

Common Pitfalls to Avoid

1. Delayed initiation of appropriate therapy: Early and aggressive treatment can prevent disease progression and improve outcomes.

2. Inadequate NSAID dosing: Many clinicians use suboptimal doses; maximum recommended doses may be needed for adequate symptom control.

3. Overreliance on analgesics: Analgesics like paracetamol and opioids should only be considered for residual pain after recommended treatments have failed, are contraindicated, or poorly tolerated 1.

4. Neglecting non-pharmacological therapy: Physical therapy and regular exercise are essential components of treatment and should not be overlooked.

5. Inappropriate use of conventional DMARDs: Sulfasalazine may be considered only in patients with peripheral arthritis, not for purely axial disease 1.

By following this evidence-based approach to the management of spondyloarthropathy of the spine, clinicians can help improve patient outcomes, reduce disease progression, and enhance quality of life.