A 26-Year-Old With Fever and Malaise Now Can't Tie His Shoes

Jeremy J. Logan, MD; Gautam Dehadrai, MD;  Herbert S Diamond, MD


September 09, 2021

Physical therapy and exercise can help prevent axial immobility in patients with ankylosing spondylitis. Specifically, spinal extension and deep-breathing exercises maintain spinal mobility, encourage erect posture, and promote chest expansion. Maintaining an erect posture and sleeping on a firm mattress with a thin pillow can help reduce thoracic kyphosis. Severe hip or spinal involvement may require surgical repair.

Nonsteroidal anti-inflammatory agents (NSAIDs) are recommended as the initial medications. No evidence supports a preference for one over another. Continuous dosing is more effective than intermittent dosing. When NSAIDs produce inadequate disease control, the preferred next treatment choice is a tumor-necrosis factor (TNF) inhibitor. Any one of the 5 available agents (adalimumab, etanercept, infliximab, golimumab, certolizumab pegol) may be used. They are highly effective at controlling inflammation and may slow disease progression. If a TNF-inhibitor fails to control disease, then guidelines recommend switching to an interleukin-17 (IL-17) inhibitor, either secukinumab or ixekizumab.

The patient in this case was started by his primary care provider on indomethacin to reduce pain and decrease inflammation. He was referred by the primary care provider to a rheumatologist for further evaluation and management and ongoing medical treatment. He was also referred to a physical therapist to begin a proper exercise and stretching program. Information regarding support groups to provide further education on the disease process and available treatment options were also given to the patient.


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