What is the primary care treatment approach for severe arthritis in the lower spine?

Primary Care Treatment for Severe Lower Spine Arthritis

For severe arthritis in the lower spine (axial spondyloarthritis), start with NSAIDs at maximum tolerated doses as first-line treatment, combined with patient education, regular exercise, and physical therapy, then refer to rheumatology if symptoms persist despite 2-4 weeks of optimal NSAID therapy or if there are difficulties with daily activities. 1, 2

Initial Pharmacologic Management

NSAIDs as First-Line Therapy

• Prescribe NSAIDs at maximum tolerated doses, weighing cardiovascular and gastrointestinal risks against benefits 1, 2
• Continuous NSAID use is preferred over on-demand dosing for patients who respond well and remain symptomatic 1
• Approximately 75% of patients with axial spondyloarthritis show good or very good response within 48 hours of full-dose NSAID therapy 1
• If the first NSAID is ineffective after 2-4 weeks, trial a different NSAID before escalating therapy 2
• For patients with gastrointestinal risk factors, consider COX-2 selective NSAIDs or add gastroprotective agents 1

Second-Line Analgesics

• Reserve paracetamol and opioid medications only for residual pain after NSAIDs have failed, are contraindicated, or poorly tolerated 1, 2
• These agents do not address the underlying inflammation and should not be first-line 1

Corticosteroid Use

• Local corticosteroid injections may be considered for specific sites of musculoskeletal inflammation 1
• Avoid long-term systemic corticosteroids for axial disease—there is no evidence supporting their use 1

Non-Pharmacologic Interventions

Exercise and Physical Therapy

• All patients must be educated about their condition and encouraged to exercise regularly 1
• Structured physical therapy programs should be considered and are often more beneficial than home exercises alone 2
• Smoking cessation is essential, as smoking worsens disease progression 1
• Regular exercise improves pain, stiffness, and function 1

When to Refer to Rheumatology

Immediate Referral Criteria

Refer patients with chronic low back pain (>3 months) starting before age 45 who have inflammatory back pain characterized by: 1, 2, 3

• Insidious onset before age 35-45 years
• Morning stiffness lasting >30 minutes
• Improvement with exercise but not rest
• Waking at night due to back pain
• Alternating buttock pain
• Good response to NSAIDs within 48 hours

Additional Referral Triggers

• Persistently high disease activity despite 2-4 weeks of optimal NSAID therapy 1, 2
• Difficulties performing activities of daily living despite NSAID treatment 2
• Presence of peripheral arthritis, enthesitis, or dactylitis 3
• Extra-articular manifestations: uveitis (immediate ophthalmology referral), psoriasis, or inflammatory bowel disease 2, 3
• Positive HLA-B27 or evidence of sacroiliitis on imaging 1, 4
• First-degree relative with spondyloarthritis 1

Important Clinical Pitfalls

Diagnostic Considerations

• Do not rule out axial spondyloarthritis based solely on negative HLA-B27 or normal inflammatory markers (ESR/CRP) 2
• The typical delay between symptom onset and diagnosis is 5-7 years—maintain high clinical suspicion 1, 2
• Plain radiographs may be normal early in disease; MRI is more sensitive for detecting sacroiliitis 1

Medications to Avoid

• Do not use conventional DMARDs (methotrexate, sulfasalazine, leflunomide) for purely axial disease—they are ineffective 1
• Sulfasalazine may only be considered if peripheral arthritis is present 1

Pre-Referral Workup

Before referring to rheumatology, obtain: 4

• ESR and CRP
• HLA-B27 testing
• Complete blood count
• Consider plain radiographs of sacroiliac joints (though MRI is more sensitive)

Treatment Escalation Beyond Primary Care

For patients referred to rheumatology with persistently high disease activity despite NSAIDs and physical therapy, biologic DMARDs (TNF inhibitors or IL-17 inhibitors) become the next treatment step 1. This escalation should be coordinated by the rheumatologist, as these patients require specialized monitoring and disease activity assessment 1.