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Could that back pain be caused by ankylosing spondylitis?

The Journal of Family Practice. 2019 May;68(4):E1-E6
May 8, 2019|Family Medicine
Carlton J. Covey, MD, FAAFP;Lee T. Church, MD, FAWM
Author and Disclosure Information

Nellis Family Medicine Residency, Las Vegas, Nev (Drs. Covey and Church); Uniformed Services University of the Health Sciences, Las Vegas, Nev (Dr. Covey)
carlton.j.covey.mil@mail.mil

The authors reported no potential conflict of interest relevant to this article.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Air Force Medical Department or the US Air Force at large.

It can often take years for patients with this condition to learn the true cause of their pain. But this guide to the work-up can help speed the diagnostic process.

PRACTICE RECOMMENDATIONS

› Evaluate all patients with back pain lasting > 3 months for inflammatory back pain features. C

› Treat all patients with confirmed or suspected axial spondyloarthritis with a trial of nonsteroidal anti-inflammatory drugs. A

› Recommend that all patients with back pain—including those with suspected axial spondyloarthritis—start an exercise program that includes both strength and aerobic activities. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Nonpharmacologic treatment, such as regular aerobic exercise and strength training, should be prescribed for all patients with axSpA.6 Regular exercise is helpful in improving lower back pain, function, and spinal mobility. Combination endurance and strength-training programs are associated with the greatest benefits, and aquatic therapy is better than land-based therapy for pain.15 That said, recommend land-based exercises over no exercise when pool-based therapy is unavailable.

NSAIDs (eg, ibuprofen 200-800 mg at variable frequency, up to a maximum dose of 2400 mg/d; naproxen 250-500 mg bid) are the core treatment for patients with axSpA, as they improve pain, function, and quality of life.6 Both traditional NSAIDs and cyclooxygenase II (COX-II) inhibitors are effective; no differences in efficacy exist between the classes.6,15,16

Prompt diagnosis of patients with ankylosing spondylitis is important because those diagnosed after significant sacroiliitis is visible are less responsive to treatment.

NSAIDs have been shown to be as safe as placebo for up to 12 weeks of continuous use in patients without gastritis or renal disease.16 In patients with a gastrointestinal comorbidity, use NSAIDs cautiously.17

 

If adequate pain relief is not obtained after 2 to 4 weeks of NSAID use, try a different NSAID prior to escalating treatment.6 More research is needed to evaluate the effect of NSAIDs on spinal radiographic progression of disease because of conflicting results of existing studies.16

Unlike with other rheumatologic disorders, oral glucocorticoids and traditional disease-modifying anti-rheumatic drugs (DMARDs) are not effective in axSpA and should not be prescribed.18

Continue to: Other agents

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