How to manage a 70-year-old male with suspected ankylosing spondylitis, currently on prednisone (corticosteroid) taper, experiencing recurring symptoms, pending rheumatologist consult?

Management of Suspected Ankylosing Spondylitis in a 70-Year-Old Male on Prednisone Taper with Recurring Symptoms

For a 70-year-old male with suspected ankylosing spondylitis (AS) experiencing recurring symptoms while on prednisone taper, NSAIDs should be initiated as first-line therapy while expediting rheumatology consultation, as systemic glucocorticoids are not recommended for axial disease management. 1

Immediate Management Steps

1. Discontinue prednisone taper gradually:

   • Prednisone is not recommended for axial AS management 1
   • Taper slowly using 1 mg decrements every 2-4 weeks to avoid adrenal insufficiency 2
   • Do not abruptly stop due to risk of adrenal crisis

2. Initiate NSAID therapy:

   • Start NSAIDs at maximum tolerated dose 3, 1
   • No particular NSAID is preferred over others 1
   • Consider cardiovascular, gastrointestinal, and renal risks when prescribing 3
   • For persistent symptoms, continuous NSAID treatment is preferred over on-demand treatment 3, 1

3. Physical therapy and exercise:

   • Strongly recommend physical therapy 3
   • Advise regular exercise focusing on spinal mobility and posture 1
   • Consider formal group or individual self-management education 3

4. Expedite rheumatology consultation:

   • Request urgent appointment given patient's age and recurring symptoms
   • Ensure proper diagnostic workup is completed before appointment

Diagnostic Evaluation While Awaiting Rheumatology Consultation

1. Laboratory assessment:

   • Monitor CRP and ESR at regular intervals 3, 1
   • HLA-B27 testing if not already done
   • Complete blood count, comprehensive metabolic panel

2. Imaging studies:

   • Order sacroiliac joint X-rays if not already done
   • Consider MRI of sacroiliac joints and spine for early detection of inflammation 3
   • DXA scan for osteoporosis screening (especially important in elderly patients) 3, 1

3. Disease activity assessment:

   • Use validated AS disease activity measures (BASDAI or ASDAS) 3
   • Document baseline scores for future comparison

Treatment Escalation (If Needed Before Rheumatology Consultation)

If symptoms persist despite NSAID therapy for 2-4 weeks:

1. For predominantly peripheral symptoms:

   • Consider local glucocorticoid injections for peripheral joint involvement 3
   • Sulfasalazine may be considered for peripheral arthritis 3, 1

2. For predominantly axial symptoms:

   • Continue NSAIDs at maximum tolerated dose
   • Avoid methotrexate as there is no evidence for efficacy in axial disease 3, 1
   • Biologics (TNF inhibitors or IL-17 inhibitors) should be considered by rheumatologist if NSAIDs fail 3, 1

Important Considerations

1. Age-specific concerns:

   • Evaluate fall risk and provide counseling 3
   • Consider comorbidities that may affect treatment choices
   • Monitor more closely for medication side effects

2. Extra-articular manifestations:

   • Screen for uveitis, inflammatory bowel disease, and psoriasis
   • If acute iritis present, refer to ophthalmologist immediately 3
   • For recurrent iritis, consider prescription of topical glucocorticoids for prompt at-home use 3

3. Monitoring for complications:

   • Assess for spinal fractures if significant change in symptoms occurs 3
   • Evaluate for advanced hip arthritis which may require total hip arthroplasty 3

Patient Education

• Explain the chronic nature of AS and importance of adherence to treatment
• Emphasize the role of regular exercise in maintaining spinal mobility
• Discuss expected outcomes and realistic treatment goals
• Provide information on support groups and resources

Common Pitfalls to Avoid

1. Relying on systemic corticosteroids for long-term management:

   • Systemic glucocorticoids are not effective for axial disease and not recommended for active AS 1
   • May mask symptoms without modifying disease progression

2. Delaying appropriate treatment:

   • Early effective treatment is crucial to prevent structural deformities 1
   • Don't wait for definitive diagnosis to start NSAIDs if AS is strongly suspected

3. Inadequate pain management:

   • Ensure pain is adequately controlled while awaiting rheumatology consultation
   • Consider appropriate analgesics if NSAIDs provide insufficient relief

4. Overlooking osteoporosis risk:

   • Both AS and prior corticosteroid use increase osteoporosis risk
   • Ensure calcium and vitamin D supplementation 2
   • DXA scan of both spine and hips is recommended 3