What is the treatment for spondyloarthropathy?

Treatment of Spondyloarthropathy

Start with NSAIDs as first-line therapy at the lowest effective dose, escalate to TNF inhibitors if disease remains active despite NSAID treatment for 2-4 weeks, and strongly avoid systemic glucocorticoids. 1

Initial Pharmacologic Management

First-Line: NSAIDs

• NSAIDs are strongly recommended as the cornerstone of initial therapy for all patients with active spondyloarthropathy 1, 2
• Begin with the lowest effective dose and monitor continuously 1
• If the first NSAID is ineffective after 2-4 weeks, switch to a different NSAID before considering escalation 1
• For patients with persistently active disease, continuous NSAID therapy is preferred over on-demand use, as continuous use may retard radiographic spinal progression 1, 3, 4
• High-quality evidence demonstrates NSAIDs reduce pain by 16.5 points on a 100mm VAS (NNT=4), improve BASDAI by 17.5 points (NNT=3), and improve BASFI by 9.1 points (NNT=5) at 6 weeks 3

NSAID Selection

• No particular traditional NSAID is preferred over another, though indomethacin may cause more neurological adverse events 3
• COX-2 inhibitors and traditional NSAIDs show equivalent efficacy (pain reduction 21.7 vs 16.5 points respectively) with no significant difference in serious adverse events 3
• COX-2 inhibitors may be considered in patients at higher risk for gastrointestinal complications 3, 4

Second-Line: Biologic Therapy

TNF Inhibitors

• Strongly recommend TNF inhibitors when disease remains active despite adequate NSAID trial 1
• No specific TNF inhibitor is preferred in most patients 1
• Exception: For patients with concomitant inflammatory bowel disease or recurrent iritis, strongly recommend TNF inhibitor monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) over etanercept 1

Treatment Algorithm for TNF Inhibitor Failure

• For primary non-response to first TNF inhibitor: conditionally recommend IL-17 inhibitors (secukinumab, ixekizumab) over switching to a different TNF inhibitor 1, 2
• For secondary non-response to first TNF inhibitor: conditionally recommend switching to a different TNF inhibitor over non-TNF biologics 1, 2
• Secukinumab is FDA-approved for ankylosing spondylitis and non-radiographic axial spondyloarthritis at 150mg subcutaneous with or without loading dose (Weeks 0,1,2,3,4) then every 4 weeks 5

Medications to Avoid

Systemic Glucocorticoids

• Strongly recommend AGAINST systemic glucocorticoids for axial spondyloarthropathy 1
• Local glucocorticoid injections may be considered for isolated active sacroiliitis, stable axial disease with active enthesitis, or stable axial disease with active peripheral arthritis 2

Conventional Synthetic DMARDs

• Sulfasalazine, methotrexate, and leflunomide have limited evidence for axial disease 1, 6
• Sulfasalazine may be considered for patients with peripheral arthritis or high disease activity, particularly in those with short disease duration 6

Non-Pharmacologic Management

Physical Therapy and Exercise

• Strongly recommend physical therapy for all patients with active spondyloarthropathy 1, 2
• Conditionally recommend supervised exercise programs over passive interventions 2
• Conditionally recommend land-based physical therapy over aquatic therapy 2
• All patients should be referred to a subspecialist for a structured exercise program 1

Special Populations and Circumstances

Peripheral Spondyloarthropathy

• First-line: corticosteroid injections for non-progressive monoarthritis 1
• Standard DMARDs (sulfasalazine, methotrexate) for peripheral polyarthritis, oligoarthritis, and persistent monoarthritis 1
• NSAIDs can be added to DMARDs at the lowest effective dose 1

Advanced Hip Arthritis

• Strongly recommend total hip arthroplasty for patients with advanced hip arthritis 1, 2

Acute Anterior Uveitis

• Immediate referral to ophthalmology is warranted for eye pain or redness 1

Monitoring and Treatment Targets

Disease Activity Assessment

• Conditionally recommend regular monitoring using validated disease activity measures (BASDAI, ASDAS) and inflammatory markers (CRP, ESR) 1, 2
• HLA-B27 is positive in 74-89% of patients but should not be used to rule out disease if negative 7
• Normal CRP or ESR does not exclude active disease 7

Treatment Goals

• Primary goal: clinical remission/inactive disease of musculoskeletal involvement 2
• Low/minimal disease activity is an acceptable alternative when remission cannot be achieved 2
• Goals include reducing symptoms, maintaining spinal flexibility and normal posture, reducing functional limitations, and maintaining work ability 1

Critical Pitfalls to Avoid

• Never use systemic glucocorticoids for axial disease - this is a strong recommendation against their use 1
• Do not perform spinal manipulation in patients with spinal fusion or advanced spinal osteoporosis - strongly recommended against 2
• Do not rule out spondyloarthropathy based on negative HLA-B27 alone - approximately 10% of AS cases are HLA-B27 negative 7
• Do not assume NSAID failure after trying only one agent - trial at least two different NSAIDs at adequate doses for 2-4 weeks each before escalating 1
• Do not delay TNF inhibitor initiation in patients with persistently active disease despite NSAIDs - early biologic therapy may prevent structural progression 1