A 36-year-old man with known ankylosing spondylitis for the last 7 years comes to the physician complaining of persistent back pain. He describes aching pain at night and in the morning that slowly goes away during the day. In the evening, he feels fine and prefers to do most of his activities then. He takes high-dose naproxen, which previously relieved his pain but recently has had only moderate effect. He was evaluated for right hip pain 6 months ago, but no joint involvement was diagnosed.
His vital signs are within normal limits. Examination shows limited spinal mobility and sacroiliac joint tenderness.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient?

Question

A 36-year-old man with known ankylosing spondylitis for the last 7 years comes to the physician complaining of persistent back pain.  He describes aching pain at night and in the morning that slowly goes away during the day.  In the evening, he feels fine and prefers to do most of his activities then.  He takes high-dose naproxen, which previously relieved his pain but recently has had only moderate effect.  He was evaluated for right hip pain 6 months ago, but no joint involvement was diagnosed.
His vital signs are within normal limits.  Examination shows limited spinal mobility and sacroiliac joint tenderness.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

NSAIDs are the first-line therapy for all symptomatic ankylosing spondylitis (AS) patients, unless contraindicated. It is usually the only medication required as 70%-80% of AS patients report substantial pain relief. Regardless of which NSAID is used, the maximum dose for at least 4 weeks is recommended before considering therapeutic failure. In addition, these patients can benefit from supervised physical therapy (eg, postural training, range-of-motion stretching), smoking cessation, and local heat or cold packs. If pain relief is not satisfactory, as in this patient, adding a tumor necrosis factor (TNF) inhibitor is the next step. Active infection and latent tuberculosis should be excluded prior to TNF inhibitor use. (Choices B and D) Although disease-modifying agents show some benefit, TNF antagonists are more effective for both the axial and peripheral arthritis seen in AS. Disease-modifying agents are often used as an alternative for peripheral arthritis when TNF antagonists are ineffective. (Choice C) Systemic or intra-articular corticosteroids may provide short-term relief. However, they can exacerbate the existing bone loss seen in these patients and should not be used long term. (Choice E) There is insufficient evidence to show that thalidomide is useful in AS. Educational objective: NSAIDs are the first-line therapy for all symptomatic ankylosing spondylitis patients, unless contraindicated. These patients can also benefit from supervised physical therapy (eg, postural training, range-of-motion stretching), smoking cessation, and other pain relief measures such as local heat or cold packs. The addition of a tumor necrosis factor inhibitor is the next step for persistent pain. __________ References: Early referral recommendations for ankylosing spondylitis (including pre-radiographic and radiographic forms) in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/15528281)

A 36-Year-Old Man with Known Ankylosing Spondylitis for the Last