What are the treatment options for spondylopathy?

Treatment of Spondylopathy

NSAIDs are the first-line pharmacological treatment for spondylopathy (axial spondyloarthritis/ankylosing spondylitis), with continuous rather than on-demand dosing recommended for active disease, followed by TNF inhibitors for patients with inadequate response to NSAIDs. 1

Initial Pharmacological Management

First-Line: NSAIDs

• Start with NSAIDs at full dose as the primary drug treatment for all patients with active spondylopathy 1
• Use continuous daily NSAID therapy rather than on-demand dosing once diagnosis is established, as 75% of patients show good or very good response within 48 hours (compared to only 15% with mechanical back pain) 1, 2
• Trial each NSAID for 2-4 weeks at optimal dosage before switching to another agent if ineffective 2
• No specific NSAID is preferred over others, though COX-2 selective NSAIDs may be chosen for long-term treatment due to reduced gastrointestinal side effects 1
• Continuous NSAID use may retard radiographic spinal progression, particularly in patients with elevated CRP 3, 4

Adjunctive Non-Pharmacological Therapy

• Refer all patients to structured exercise programs and physical therapy immediately upon diagnosis 1, 2
• Home-based exercises are effective and should be recommended to all patients 2

Second-Line: Biologic DMARDs

When to Escalate Therapy

Initiate biologic therapy when patients have:

• High disease activity despite adequate trial of at least two NSAIDs (or intolerance/contraindication to NSAIDs) 1
• AND elevated CRP and/or definite inflammation on MRI and/or radiographic sacroiliitis 1

TNF Inhibitors (Preferred Initial Biologic)

• TNF inhibitors are strongly recommended over no biologic treatment for NSAID-refractory disease 1
• Available agents include infliximab, etanercept, adalimumab, certolizumab, golimumab, and their biosimilars 1, 5
• No particular TNF inhibitor is preferred, except in specific comorbidities (see below) 1
• Approximately 50% of NSAID-refractory patients achieve 50% improvement with TNF inhibitors, with 72% response rate in patients with disease duration <10 years 1

IL-17 Inhibitors (Alternative Biologics)

• Secukinumab or ixekizumab are strongly recommended over no treatment for NSAID-refractory disease 1
• TNF inhibitors are conditionally preferred over IL-17 inhibitors as initial biologic therapy 1

Management of Treatment Failure

After First TNF Inhibitor Fails

• For primary non-response (never worked): Consider switching to secukinumab or ixekizumab over another TNF inhibitor 1
• For secondary non-response (stopped working): Switch to a different TNF inhibitor over a non-TNF biologic 1

Special Populations and Comorbidities

Inflammatory Bowel Disease

• Use TNF monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) rather than etanercept 1
• Avoid NSAIDs that may worsen IBD symptoms, though no specific NSAID is definitively contraindicated 1

Recurrent Uveitis/Iritis

• Prefer TNF monoclonal antibodies over other biologics for patients with recurrent eye inflammation 1
• Ensure ophthalmology referral for acute episodes 1

Peripheral Arthritis

• Consider sulfasalazine or methotrexate only in patients with prominent peripheral joint involvement or when TNF inhibitors are unavailable 1
• These agents have minimal efficacy for axial disease 1

Medications to Avoid

• Systemic glucocorticoids are strongly NOT recommended for axial spondylopathy 1
• Conventional synthetic DMARDs (except for peripheral arthritis) have no proven efficacy for axial disease 1

Monitoring and Treatment Goals

• Monitor disease activity using validated measures (BASDAI, ASDAS) and acute phase reactants (CRP, ESR) at regular intervals 1
• Target clinical remission or inactive disease as the primary treatment goal 2
• Adjust therapy if treatment targets are not met within appropriate timeframes 1, 2

Surgical Considerations

• Total hip arthroplasty is strongly recommended for patients with advanced hip arthritis 1
• Spinal osteotomy should be avoided except in highly selected cases of severe kyphosis 1

Important Caveats

• Early diagnosis is critical as there is typically a 5-7 year delay between symptom onset and diagnosis 1, 2
• Long-term NSAID use requires monitoring for gastrointestinal, renal, and cardiovascular adverse effects 4
• Do not discontinue biologics abruptly in patients achieving sustained remission; consider dose tapering instead 1
• Methotrexate co-treatment with TNF inhibitors is conditionally recommended against (no added benefit) 1