Skill Checkup: A 44-Year-Old Man With Moderate to Severe Lower Back Pain Despite Treatment

Marina Magrey, MD


April 05, 2023

Several possibilities exist for the third-line treatment of this patient. Switching to another TNF inhibitor would be an appropriate step, given data suggesting that a second TNF inhibitor may be efficacious in patients in whom a first TNF inhibitor has failed.

According to both the Assessment of SpondyloArthritis international Society (ASAS)/ European Alliance of Associations for Rheumatology (EULAR) and American College of Rheumatology (ACR) guidelines, local glucocorticoid injections are typically reserved for patients with predominately peripheral manifestations, because they have not been shown to be efficacious in patients with predominately axial symptoms, like the case patient. Similarly, according to the same guidelines, treatment with sulfasalazine is recommended primarily for patients with prominent peripheral arthritis and few or no axial symptoms because they are unlikely to be of significant benefit.

In adults with active ankylosing spondylitis despite treatment with the first TNF inhibitor used, the ACR guidelines strongly recommend against switching to treatment with a biosimilar of the first TNF inhibitor because the clinical response is unlikely to be different.

Methotrexate is not routinely prescribed for patients with axial SpA because it has not been shown to be effective.

The patient's therapy is switched to adalimumab, 40 mg every other week.


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