Axial spondyloarthritis (ankylosing spondylitis)

• Non-radiographic (MRI inflammation only) or radiographic (ankylosing spondylitis, X-ray sacroiliitis).

• Back pain for more than 3 months starting before 45 years, better with activity and worse with rest, night and buttock pain, stiffness; peripheral arthritis, enthesitis, dactylitis, uveitis; psoriasis or IBD.

• Investigations: HLA-B27 (80–90%), CRP/ESR, pelvic X-ray, MRI of sacroiliac joints; ASAS 2009 criteria.

Management

• Daily spinal extension and mobility exercises, physiotherapy, posture training, stop smoking, stay active.

NSAIDs (first-line, continuous or on demand)

• A: Ibuprofen (PO) 400–800 mg every 8 hours,

• OR C: diclofenac (PO) 50 mg every 8–12 hours (or diclofenac gel 1% every 6 hours),

• OR A: piroxicam (PO) 20 mg once daily, OR D: meloxicam (PO) 7.5–15 mg once daily,

• OR S: ketoprofen (PO) 75 mg every 8 hours (or ketoprofen gel 2.5% every 6 hours).

• Add a PPI when the risk of NSAID gastrointestinal complications is high.

• If NSAIDs are insufficient: S: adalimumab (SC) 40 mg every 2 weeks.

• Conventional DMARDs have no proven efficacy in axial disease.

• Surgery: corrective osteotomy for severe kyphosis, fusion for unstable fractures, decompression, hip replacement.