What is the recommended management approach for a patient with spine arthritis?

Management of Spine Arthritis

For patients with spine arthritis (axial spondyloarthritis), NSAIDs at maximum tolerated doses are the mandatory first-line pharmacological treatment, combined with patient education and regular supervised exercise programs. 1, 2

Initial Pharmacological Management

NSAIDs form the cornerstone of drug therapy and should be initiated immediately in all patients with pain and stiffness. 1, 2

• Start with NSAIDs at maximum tolerated doses, weighing cardiovascular, gastrointestinal, and renal risks before prescribing 1, 2
• For patients with elevated GI risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1, 3
• If the first NSAID fails after 2-4 weeks of adequate dosing, switch to a different NSAID 2
• Continuous NSAID treatment is strongly preferred over on-demand dosing for patients with persistently active, symptomatic disease 1
• Expect onset of pain relief within 1 hour for naproxen and within 48 hours for most patients (75% response rate) 2, 4

Specific NSAID Dosing for Ankylosing Spondylitis

• Naproxen: 250-500 mg twice daily; may increase to 1500 mg/day for up to 6 months in refractory cases 4
• Morning and evening doses do not need to be equal 4

Non-Pharmacological Treatment (Equally Important as Medications)

All patients must be enrolled in a structured exercise program from the time of diagnosis—this is not optional. 1, 2, 5

• Supervised physical therapy programs are superior to home exercises alone and should be the preferred approach 5, 3
• Target ≥150 minutes/week of moderate-intensity aerobic exercise OR ≥75 minutes/week of vigorous-intensity exercise 5
• Include resistance/strength training ≥2 sessions per week 5
• Home exercises are acceptable only after proper training on correct technique, acknowledging healthcare access limitations 5
• Patient education about the disease, smoking cessation counseling, and encouragement of regular exercise are mandatory 1, 2

Critical Safety Warning for Exercise

Spinal manipulation is absolutely contraindicated in patients with spinal fusion or advanced spinal osteoporosis due to serious adverse event risk. 5

When NSAIDs and Physical Therapy Fail

For Purely Axial Disease

Do NOT use conventional synthetic DMARDs (methotrexate, sulfasalazine, leflunomide) for axial symptoms—they are completely ineffective for spinal disease. 1, 3

Escalation to Biologic Therapy

Patients with persistently high disease activity despite adequate trials of NSAIDs and physical therapy should be started on TNF inhibitor therapy. 1, 3

• There is NO requirement to fail DMARDs before starting TNF inhibitors in axial disease 1, 3
• Current practice is to start with a TNF inhibitor as the first biologic 1
• If the first TNF inhibitor fails, switch to either another TNF inhibitor or an IL-17 inhibitor (secukinumab or ixekizumab) 1
• Evaluate response after at least 12 weeks of biologic therapy 1
• Treatment target: ASDAS <1.3 or BASDAI <2 1

For Peripheral Arthritis (When Present)

• Sulfasalazine may be considered specifically for peripheral joint involvement 1, 3
• Local corticosteroid injections directed to the site of musculoskeletal inflammation may be used 1, 3
• Avoid long-term systemic glucocorticoids for axial disease—there is no evidence of benefit 1, 3

Analgesics for Residual Pain

• Paracetamol and opioid-like drugs should only be considered after NSAIDs, physical therapy, and biologics have failed, are contraindicated, or poorly tolerated 1, 2

Disease Monitoring Strategy

Treatment should be guided by a predefined treatment target agreed upon between patient and rheumatologist, with clinical remission/inactive disease as the major goal. 1, 2

• Monitor disease activity using validated measures (BASDAI or ASDAS), clinical signs, symptoms, and acute phase reactants 1, 2
• Frequency of monitoring should be individualized based on symptoms, severity, and treatment 1
• Spinal radiographs should NOT be repeated more frequently than every 2 years unless clearly indicated 1
• In patients with unclear disease activity while on a biologic, obtain spinal or pelvis MRI to assess inflammation 1

Surgical Interventions

Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age. 1, 3

• Spinal corrective osteotomy may be considered in patients with severe disabling deformity, but only in specialized centers 1, 3
• If acute vertebral fracture is suspected (sudden change in symptoms), consult a spinal surgeon immediately—these fractures are more common than expected and can occur without trauma 1

Screening and Comorbidity Management

• Screen for osteopenia/osteoporosis with DXA scan, including both spine and hips in patients with syndesmophytes or spinal fusion 1
• Be aware of increased cardiovascular disease risk in these patients 1, 3
• Immediate ophthalmology referral for any symptoms of uveitis (eye pain or redness) 2

Critical Pitfalls to Avoid

• Do NOT delay diagnosis based solely on negative HLA-B27 or normal inflammatory markers 2
• Do NOT prescribe DMARDs for axial symptoms expecting spinal benefit 1, 3
• Do NOT require DMARD failure before initiating TNF inhibitor therapy in axial disease 1, 3
• Do NOT use systemic corticosteroids for axial disease 1, 3
• Do NOT perform spinal manipulation in patients with fusion or advanced osteoporosis 5
• Do NOT neglect exercise therapy—it is as important as medication 1, 5, 3

When to Refer to Rheumatology

Refer patients with suspected axial spondyloarthritis who have back pain starting before age 45 that has lasted >3 months, plus at least 4 of the following: 2

• Back pain occurring before age 35
• Waking at night due to symptoms
• Buttock pain
• Improvement with movement or within 2 days of NSAID use
• First-degree relative with spondyloarthritis
• Current or previous arthritis, enthesitis, or psoriasis

Also refer patients with persistently high disease activity despite NSAIDs or those with difficulties in daily activities despite NSAID treatment 2