Initial Management Approach for Uncovertebral Spondylitis

NSAIDs are recommended as first-line drug treatment for uncovertebral spondylitis with pain and stiffness. 1

Assessment and Diagnosis

Treatment should be tailored according to current manifestations of the disease (axial, peripheral, entheseal involvement), level of symptoms, disease activity/inflammation, pain, and functional status 1
Disease monitoring should include patient history, clinical parameters, laboratory tests (ESR, CRP), and imaging according to clinical presentation 1
Assessment tools such as BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) should be used to evaluate disease activity and response to treatment 1

NSAIDs:
- Should be initiated as the first pharmacological intervention 1
- Can be used at maximum recommended or tolerated anti-inflammatory dose for at least 3 months 1
- Evidence shows NSAIDs improve spinal pain, peripheral joint pain, and function over a short time period (6 weeks) 1
- Consider continuous rather than on-demand NSAID treatment, as evidence suggests continuous treatment may retard radiographic disease progression 1, 2
NSAID Selection:
- No specific NSAID has been shown to be clearly superior to others for spondylitis 1
- For patients with increased gastrointestinal risk, options include:
  - Non-selective NSAIDs plus a gastroprotective agent (PPI or H2 blocker) 1
  - COX-2 selective inhibitor 1
- Consider cardiovascular risk factors when selecting between traditional NSAIDs and COX-2 inhibitors 1

Should be implemented concurrently with pharmacological treatment 1
Include:
- Patient education about the condition 1
- Regular exercise program 1
- Individual and group physical therapy 1
- Home exercise to improve function 1

Analgesics:
- Consider paracetamol (acetaminophen) and opioids for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
Local Corticosteroid Injections:
- May be considered for local site of musculoskeletal inflammation 1
- Particularly useful for enthesopathy 3
For Peripheral Joint Involvement:
- Consider sulfasalazine if peripheral arthritis is present and unresponsive to NSAIDs 1, 3
- Sulfasalazine has shown efficacy primarily in patients with peripheral joint involvement 3
For Refractory Disease:
- Anti-TNF treatment should be given to patients with persistently high disease activity despite conventional treatments 1
- Consider anti-TNF therapy if disease remains active (BASDAI >4) after trials of at least two NSAIDs 1

Evaluate response between 6-12 weeks after initiating treatment 1
Response criteria: 50% relative change or absolute change of 20 mm in BASDAI (on a scale of 0-100) 1
Monitor for adverse events, particularly gastrointestinal and cardiovascular complications with NSAIDs 1

NSAID-related risks:
- Gastrointestinal toxicity is dose-dependent and increases with age and concomitant corticosteroid use 1
- Consider cardiovascular risk factors when selecting between traditional NSAIDs and COX-2 inhibitors 1
- Monitor for hypertension, abdominal pain, and dyspepsia, which may occur more frequently with continuous NSAID use 2
Treatment failures:
- Ensure adequate therapeutic trials of at least two NSAIDs before considering treatment failure 1
- An adequate trial is defined as treatment for at least 3 months at maximal recommended or tolerated dose 1
Differential diagnosis:
- Rule out infectious causes of spondylitis, particularly pyogenic and tuberculous spondylitis, which require specific antimicrobial therapy 4
- Pyogenic spondylitis typically presents with higher CRP levels and more severe clinical course 4
Radiographic progression:
- Consider continuous rather than on-demand NSAID treatment, as evidence suggests this approach may reduce radiographic progression 2
- This effect may be more pronounced in patients with elevated CRP levels 5