What are the treatment options for axial pain?

Treatment Options for Axial Pain

NSAIDs at maximum tolerated dose represent first-line pharmacologic therapy for axial pain, with continuous use preferred over on-demand dosing for symptomatic patients, while physical therapy and structured exercise programs should be initiated concurrently. 1, 2

First-Line Treatment Approach

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• NSAIDs should be prescribed at the maximum tolerated anti-inflammatory dose for patients experiencing pain and stiffness. 1, 2
• Continuous NSAID use is preferred over on-demand dosing for patients with active disease, as this approach achieves ASAS20 response >70% and ASAS40 response in >50% of patients. 1
• If the initial NSAID proves ineffective after 2-4 weeks of continuous use at maximum dose, switch to a different NSAID before considering treatment failure. 1, 2
• Balance cardiovascular, gastrointestinal, and renal risks against benefits when prescribing NSAIDs, particularly for chronic use. 1, 3
• For patients with high gastrointestinal risk, consider gastroprotective agents or selective COX-2 inhibitors. 2, 4

Physical Therapy and Exercise

• All patients should be referred to a structured exercise program and physical therapy alongside pharmacologic treatment. 1, 2
• Supervised exercise is preferred over passive physical therapy interventions for optimal functional outcomes. 2
• Home exercises are effective and more feasible than formal physical therapy for many patients, though some require supervised therapy. 1
• Patient education about the disease and smoking cessation should be strongly encouraged. 1

Second-Line Treatment Options

When NSAIDs Fail or Are Contraindicated

For patients with persistently high disease activity (ASDAS ≥2.1 or BASDAI ≥4) despite at least 1 month of maximum-dose NSAID therapy, biological DMARDs should be initiated, with TNF inhibitors as the preferred first biologic agent. 1, 2

Biological Disease-Modifying Antirheumatic Drugs (bDMARDs)

• TNF inhibitors (TNFi) represent current standard practice as the first biologic therapy for axial disease with persistently high activity. 1, 2
• IL-17 inhibitors (secukinumab or ixekizumab) should be considered for patients with contraindications to TNFi (heart failure, demyelinating disease) or primary non-response to TNFi. 1, 2
• Avoid IL-17 inhibitors in patients with inflammatory bowel disease or recurrent uveitis; TNFi monoclonal antibodies are superior in these populations. 1, 2
• If the first TNFi fails, switching to another TNFi or to an IL-17 inhibitor should be considered. 1
• Tofacitinib (JAK inhibitor) may be considered as a second-line option for patients with contraindications to TNFi other than infections. 1

Analgesics for Residual Pain

• Analgesics (acetaminophen, opioid-like drugs) may be considered only for residual pain after NSAIDs and bDMARDs have failed, are contraindicated, or poorly tolerated. 1, 4
• This is a weak recommendation as formal evidence for analgesic efficacy in axial pain is lacking. 1
• Acetaminophen up to 4000 mg daily provides the best safety profile among analgesics when NSAIDs are contraindicated. 4

Treatments to Avoid or Use Cautiously

Glucocorticoids

• Patients with axial disease should NOT receive long-term systemic glucocorticoids regardless of dose. 1, 2
• Local glucocorticoid injections directed at specific sites of musculoskeletal inflammation (arthritis, enthesitis) may be considered, though direct evidence is lacking. 1
• Short-term high-dose systemic glucocorticoids (50 mg/day) show only very modest effects on axial symptoms. 1

Conventional Synthetic DMARDs (csDMARDs)

• Patients with purely axial disease should normally NOT be treated with csDMARDs (sulfasalazine, methotrexate, leflunomide), as these agents are not efficacious for axial symptoms. 1
• Sulfasalazine may be considered only if peripheral arthritis is present. 1
• csDMARDs may be attempted only in exceptional situations where no other pharmacological option exists due to toxicity, contraindications, or cost constraints, with full patient informed consent about low likelihood of success. 1

Treatment Monitoring and Adjustment

• Disease monitoring should include patient-reported outcomes, clinical findings, laboratory tests (CRP, ESR), and imaging when clinically indicated. 1
• Do NOT obtain routine repeat spine radiographs or MRI at scheduled intervals in stable patients, as this does not improve clinical outcomes. 1
• If a patient achieves sustained remission on bDMARD therapy, tapering can be considered. 1
• If significant change in disease course occurs, consider causes other than inflammation (such as spinal fracture) and perform appropriate evaluation including imaging. 1

Common Pitfalls to Avoid

• Underdosing NSAIDs—always use maximum tolerated anti-inflammatory doses, not subtherapeutic amounts. 1
• Switching to biologics prematurely before adequate NSAID trial (at least 1 month of continuous maximum-dose therapy). 2
• Using csDMARDs for purely axial symptoms—these are ineffective and delay appropriate treatment. 1
• Prescribing long-term systemic glucocorticoids for axial disease—this provides minimal benefit with significant harm. 1, 2
• Selecting IL-17 inhibitors for patients with IBD or uveitis—TNFi monoclonal antibodies are superior. 1, 2