What is the best course of management for a married man with one child, who works as a professional, is an occasional alcohol drinker and smoker, presenting with progressive low back pain, night pain, morning stiffness, difficulty bending, and a history of hip pain relieved by Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), with laboratory results showing signs of inflammation, including elevated Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP)?

Management of Suspected Axial Spondyloarthritis with Inflammatory Back Pain

This patient requires immediate initiation of NSAIDs at continuous dosing, urgent referral to rheumatology, and MRI of the spine and sacroiliac joints to confirm axial spondyloarthritis, followed by early progression to TNF inhibitor therapy if NSAIDs provide inadequate response within 4 weeks. 1

Immediate Diagnostic Priorities

Clinical Features Strongly Suggest Axial Spondyloarthritis

This patient presents with the classic inflammatory back pain pattern that mandates urgent evaluation:

• Night pain awakening the patient from sleep 1
• Morning stiffness upon arising 1
• Pain improved with exercise (basketball, gym) but not relieved by rest 1
• Age under 45 years with symptoms lasting more than 3 months 1
• Loss of lumbar lordosis and restricted spinal flexion/extension 1
• Sacroiliac joint tenderness and limited internal rotation of the left hip 1
• Elevated inflammatory markers (ESR and CRP) 1, 2

Urgent Imaging Required

Order MRI immediately—do not wait for plain radiographs, as they will miss early disease. 1 The MRI protocol must include:

• Sagittal images of cervicothoracic and thoracolumbar spine with T1 and STIR sequences 1
• Coronal/oblique sacroiliac joints with T1 and STIR sequences 1

Plain radiography of the spine and sacroiliac joints is inadequate for early axial spondyloarthritis and will delay diagnosis and treatment. 1

Additional Laboratory Testing

While inflammatory markers are already elevated, complete the diagnostic workup:

• HLA-B27 testing (though less frequently positive in some populations, it supports the diagnosis) 1
• Complete blood count to assess for anemia that could artificially elevate ESR 2, 3
• Rheumatoid factor and anti-CCP antibodies to exclude rheumatoid arthritis 2

Immediate Pharmacologic Management

First-Line: Continuous NSAID Therapy

Start continuous (not on-demand) NSAID treatment immediately for active disease. 1 This differs from stable disease, where on-demand dosing is preferred. 1

The patient's smoking history (a risk factor for progressive spinal fusion) and persistently elevated CRP further support continuous NSAID use in this early, active phase. 1 Continuous NSAID treatment may slow radiographic progression in patients with early disease, no comorbidities, and high propensity for fusion (men, smokers, elevated CRP, existing syndesmophytes). 1

Critical caveat: While NSAIDs are more effective than simple analgesia for axial spondyloarthritis, monitor for gastrointestinal, renal, and cardiac toxicity. 1 Short-term use is generally safe, but long-term continuous use requires ongoing risk-benefit assessment. 1

Avoid Ineffective Therapies

• Do NOT prescribe systemic corticosteroids for axial spondyloarthritis—they are ineffective for axial disease 4
• Do NOT use sulfasalazine or methotrexate for axial symptoms—these conventional DMARDs are ineffective for spinal disease (though sulfasalazine may help peripheral arthritis) 1
• Avoid opioids for long-term management 4

Non-Pharmacologic Management

Physical Therapy: Strongly Recommended

Initiate active physical therapy immediately—this is a strong recommendation even before diagnosis is confirmed. 1

• Active interventions (patient-directed exercise programs) must be prioritized over passive interventions (massage, manipulation) 1
• Physical therapy should focus on educating the patient in self-management with an independent exercise program 1
• Land-based therapy is conditionally preferred over aquatic therapy due to greater accessibility, though aquatic therapy can supplement if available 1

The goal is to prevent long-term disability through early specialist physiotherapy assessment and ongoing exercise. 1

Smoking Cessation: Critical Priority

Strongly counsel smoking cessation—smoking is a significant risk factor for progressive spinal fusion in axial spondyloarthritis. 1 While the association between smoking and general low back pain is weak and inconsistent 5, 6, smoking specifically predicts worse outcomes in inflammatory spondyloarthritis. 1

Urgent Rheumatology Referral

Refer to rheumatology immediately—do not delay. 1 Early diagnosis and treatment prevent long-term disability. 1

The rheumatologist will:

• Confirm the diagnosis based on clinical features and MRI findings 1
• Assess disease activity using validated measures 2
• Determine timing for TNF inhibitor initiation 1

Escalation to Biologic Therapy

When to Progress to TNF Inhibitors

If NSAIDs provide inadequate response after 4 weeks of continuous therapy, early progression to TNF inhibitor therapy is necessary. 1

TNF inhibitors are highly effective for axial spondyloarthritis, whereas sulfasalazine and methotrexate are not. 1 Early initiation of TNF inhibitors prevents irreversible structural damage and disability. 1

Monitoring Disease Activity

Once treatment is initiated:

• Measure ESR and CRP every 1-3 months during active disease until remission 2
• After achieving low disease activity or remission, monitor every 3-6 months 2
• Use validated composite disease activity measures (such as DAS28-ESR) alongside joint counts and patient assessments 2

Critical Red Flags to Exclude

While this presentation is classic for axial spondyloarthritis, immediately exclude spinal infection given the elevated inflammatory markers and progressive symptoms: 7

• Fever, night sweats, or unintentional weight loss suggest infection rather than inflammatory arthritis 7
• Progressive weakness, numbness, or bowel/bladder dysfunction require emergency MRI to exclude epidural abscess or cord compression 7
• Risk factors for infection (IV drug use, recent spinal procedures, diabetes, immunosuppression) mandate urgent imaging with contrast 7

The patient denied fever and weight loss, which is reassuring, but the MRI will definitively exclude vertebral osteomyelitis or epidural abscess. 7

Monitoring and Follow-Up Strategy

Short-Term (First 4 Weeks)

• Assess response to continuous NSAIDs at 2-4 weeks 1
• Obtain MRI results and confirm diagnosis with rheumatology 1
• Initiate physical therapy and ensure patient engagement in active exercise program 1
• Counsel smoking cessation 1

Medium-Term (1-3 Months)

• If inadequate response to NSAIDs, initiate TNF inhibitor therapy 1
• Monitor ESR and CRP every 1-3 months 2
• Continue physical therapy with focus on maintaining spinal mobility 1

Long-Term (Beyond 3 Months)

• Once remission or low disease activity is achieved, monitor inflammatory markers every 3-6 months 2
• Continue lifelong exercise program to prevent disability 1
• If stable on TNF inhibitor, consider withdrawing NSAIDs to reduce toxicity risk 1

Common Pitfalls to Avoid

• Do not delay imaging with MRI—plain radiographs will miss early disease and delay treatment 1
• Do not prescribe on-demand NSAIDs for active disease—continuous dosing is required for disease control 1
• Do not use sulfasalazine or methotrexate for axial symptoms—they are ineffective for spinal disease 1
• Do not rely on passive physical therapy alone—active patient-directed exercise is essential 1
• Do not delay TNF inhibitor therapy if NSAIDs fail—early biologic treatment prevents irreversible damage 1
• Do not ignore the smoking history—smoking predicts progressive fusion and must be addressed 1