What is the treatment for inflammatory changes on x-ray?

Treatment of Inflammatory Changes on X-ray

For inflammatory changes seen on x-ray in suspected axial spondyloarthritis (axSpA), treatment should begin with NSAIDs such as naproxen as first-line therapy, followed by biologic agents like TNF-α inhibitors if NSAIDs fail to control symptoms adequately. 1, 2

Diagnostic Approach Before Treatment

Before initiating treatment, it's important to confirm the diagnosis and assess disease activity:

• Radiographs are recommended as the first imaging modality for evaluation of suspected axSpA 1
• If radiographs are negative or equivocal but clinical suspicion remains high, MRI of the sacroiliac joints is the best examination for assessment of acute inflammatory changes 1
• MRI should include T1 sequences and fat-suppressed fluid-sensitive sequences such as T2-weighted fat-suppressed or STIR images 1
• CT may be helpful when equivocal radiographic abnormalities exist, allowing identification of subtle erosions and soft-tissue ossification 1

Treatment Algorithm

First-Line Treatment

• NSAIDs are the first-line pharmacologic therapy for inflammatory changes seen on x-ray 1, 2
• Naproxen has been shown to be effective in patients with ankylosing spondylitis, decreasing night pain, morning stiffness, and pain at rest 2
• Initial dosing of naproxen is typically 375-500 mg twice daily 2
• Take NSAIDs with food to reduce gastric irritation 2, 3

Physical Measures

• Simple physical methods such as adequate rest for the injured site may be beneficial in mild cases 3
• When inflammation is controlled, therapeutic exercises should be prescribed to restore range of motion, strength, and endurance 3

Second-Line Treatment

If NSAIDs fail to adequately control symptoms after 2-4 weeks of therapy:

• Biologic agents, particularly tumor necrosis factor-α (TNF-α) antagonists, are recommended 1
• These biologics have the potential to arrest disease progression and prevent the development of disability 1
• Early diagnosis and treatment before radiographic joint damage is essential 1

Corticosteroids

• For severe acute flares, short-term corticosteroids may be considered 4
• Prednisone dosing may vary from 5 mg to 60 mg per day, depending on disease severity 4
• Corticosteroid injections may be beneficial in some cases but require precautions 3

Monitoring Disease Activity

• In adults with axSpA of unclear activity while receiving a biologic, obtaining a spinal or pelvis MRI to assess activity is conditionally recommended 1
• MRI could provide useful information in cases where the level of disease activity is unclear and where this information would influence treatment decisions 1
• For patients with nonradiographic axial SpA, imaging should focus on the sacroiliac joints 1

Important Caveats

• MRI is not recommended in patients in whom disease activity is either clearly clinically active or clinically stable 1
• In adults with stable axSpA, obtaining a spinal or pelvis MRI to confirm inactivity is not recommended 1
• Routine repeat spine radiographs at scheduled intervals (e.g., every 2 years) as a standard approach is not recommended 1
• NSAIDs may increase the risk of gastrointestinal side effects, particularly at higher doses and with prolonged use 2
• Nonsteroidal anti-inflammatory drug (NSAID) use is reported to be associated with an increase in immune checkpoint inhibitor-induced colitis, so care should be taken with NSAID use in this setting 1

Special Considerations

• For patients unable to undergo MRI, CT may be helpful, demonstrating improved sensitivity over conventional radiography for detection of subtle bone erosions and reparative changes 1
• When using biologics, screening labs (HIV, hepatitis A and B, and TB testing) should be performed initially and repeated annually in patients who require biologic treatment for more than one year 1