Review Question - QID 107052

This patient's clinical presentation is consistent with ankylosing spondylitis (AS). The first-line treatment for pain in AS is indomethacin.

AS is a seronegative (ANA and rheumatoid factor negative) spondyloarthropathy associated with the HLA-B27 allele. Patients typically present with back pain that is worse in the morning and may report a history consistent with anterior uveitis. On examination, patients usually exhibit a positive Schober's test, indicating restricted anterior flexion of the spine. Radiographs may show sclerosis in the sacroiliac joints as well as a "bamboo spine" appearance. Indomethacin is the treatment of choice for pain management, along with physical therapy. Refractory cases may require treatment with TNF-alpha inhibitors or sulfasalazine.

Kataria and Brent review spondyloarthropathies. There are five categories of spondyloarthropathies: AS, psoriatic arthritis, reactive arthritis (such as Reiter's disease), inflammatory bowel disease associated arthritis, and undifferentiated spondyloarthritis. All spondyloarthropathies are associated with the HLA-B27 allele, and early treatment is recommended to slow symptom progression.

Gorman et al. perform a randomized, double-blinded, placebo-controlled trial to evaluate the efficacy of TNF-alpha inhibitors for treatment of AS. Randomly assigned patients were treated with etanercept. The primary outcomes included decreased morning stiffness, joint swelling, and back pain. Over four months of therapy, they found a significant improvement of symptoms in patients who received treatment with etanercept compared to those who received placebo. This provided evidence that TNF-alpha inhibitors are useful in the treatment of AS.

Illustration A shows the typical spinal changes that occur in AS. Illustration B is a radiograph with notable, bilateral sacroiliitis. Illustration C is a table showing the different characteristics of several spondyloarthropathies.

Incorrect Answers:
Answer 2: Methotrexate is a disease-modifying treatment commonly used for rheumatoid arthritis and sarcoidosis.
Answer 3: Cyclophosphamide is used for treatment of refractory Sjogren's syndrome, scleroderma and ANCA-associated vasculitis.
Answer 4: High-dose steroids are used for many inflammatory conditions, but are not used as first-line therapy for AS.
Answer 5: Physical therapy, not bed rest, is recommended for patients with AS.