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

Marina Magrey, MD


April 05, 2023

According to the ACR guidelines, if a patient has contraindications to TNF inhibitors and has active SpA despite treatment with nonsteroidal anti-inflammatory drugs, a IL-17 antagonist (secukinumab or ixekizumab) may be considered.

Those same guidelines state that IL-6 inhibitors, the IL-12/23 inhibitor ustekinumab, and the T-cell inhibitor abatacept are not recommended for SpA even in patients with contraindications to TNF inhibitors, because they have not been shown to be efficacious in this setting.

An exception to this would be if the contraindication to TNF inhibitor use was tuberculosis, another chronic infection, or a high risk for recurrent infections. In that scenario, sulfasalazine is preferred over secukinumab, izekizumab, and tofacitinib. In such cases, attempts should be made to mitigate the infections so that a TNF inhibitor might safely be used.

Editor's Note: Skill Checkups are wholly fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

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