MKSAP Quiz: Follow-up for ankylosing spondylitis
A 35-year-old woman is evaluated in follow-up for a recent diagnosis of ankylosing spondylitis. Despite the use of three different NSAIDs and physical therapy, she continues to have night pain and morning stiffness/pain lasting more than 1 hour. Following a physical exam and pelvic radiograph, what is the most appropriate treatment?
A 35-year-old woman is evaluated in follow-up for a recent diagnosis of ankylosing spondylitis. Despite the use of three different NSAIDs and physical therapy, she continues to have night pain and morning stiffness/pain lasting more than 1 hour.
On physical examination, vital signs are normal. There is pain at the sacroiliac joints with hip flexion, abduction, and external rotation. Lumbar spine range of motion is mildly limited. Peripheral joints are normal.
Initial anteroposterior radiograph of pelvis showed bilateral sacroiliitis.
Which of the following is the most appropriate next treatment?
A. Etanercept
B. Methotrexate
C. Prednisone
D. Sulfasalazine
MKSAP Answer and Critique
The correct answer is A. Etanercept. This content is available to MKSAP 19 subscribers as Question 14 in the Rheumatology section. More information about MKSAP is available online.
The most appropriate next treatment is etanercept (Option A). This patient has a clear diagnosis of ankylosing spondylitis (AS), and first-line therapy with NSAIDs has failed. The American College of Rheumatology (ACR) recommends the use of a tumor necrosis factor (TNF) inhibitor after failure of a trial of at least two NSAIDs for 2 to 4 weeks each, or if NSAIDs cannot be tolerated. TNF inhibitors, such as etanercept (a fusion protein), adalimumab, or infliximab (monoclonal antibodies), can be used. The selection may depend on the presence of comorbid disease, such as uveitis or inflammatory bowel disease, where the monoclonal antibodies would be more appropriate. TNF inhibitors have been shown to be disease modifying in AS. Interleukin-17 inhibitors, such as secukinumab or ixekizumab, could also be used as an alternative to TNF inhibitors or when a TNF inhibitor may be contraindicated after failure of NSAIDs. The Janus kinase inhibitors tofacitinib and upadacitinib are now approved for treatment of ankylosing spondylitis but are recommended only for patients in whom TNF inhibitors and interleukin-17 inhibitors have failed or are contraindicated.
Nonbiologic disease-modifying antirheumatic drugs, such as methotrexate (Option B) or sulfasalazine (Option D), have no efficacy in axial disease and limited efficacy in peripheral disease. Treatment with sulfasalazine is recommended primarily for patients with prominent peripheral arthritis and few or no axial skeleton symptoms and in these patients, it may be more effective than methotrexate. However, a TNF inhibitor may be the best option for these patients.
The ACR strongly recommend against treatment with systemic glucocorticoids, such as prednisone (Option C). Glucocorticoids have numerous adverse effects, which are more likely to occur with higher doses and longer treatment, and lower doses are not as efficacious as TNF inhibitors.
Key Point
- Tumor necrosis factor inhibitors are useful in patients with ankylosing spondylitis in whom NSAIDs have failed or cannot be tolerated.