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

Marina Magrey, MD


April 05, 2023

If the patient does not achieve a positive response (ie, evidence of substantially decreased disease activity), treatment with another biological disease-modifying antirheumatic drug (DMARD) (ie, a TNF inhibitor or an interleukin [IL]-17 inhibitor) or a Janus kinase (JAK) inhibitor should be considered. However, a JAK inhibitor should be used with caution in patients > 50 years with one or more additional cardiovascular risk factors and in those > 65 years owing to uncertainty regarding its impact on cardiovascular risk.

Leflunomide has not been shown to be effective in axial SpA and is therefore not recommended.

Bisphosphonates are not recommended for treatment of axial SpA.

Oral corticosteroids are not recommended for axial disease. They should be used only for short-term management of peripheral arthritis; long-term management carries a high risk for adverse effects and should be strictly avoided.


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