Young man, inflammatory back pain, ↓chest expansion
Confirm: HLA-B27; SI joint / LS spine X-ray or MRI
Treat: NSAIDs + exercise/PT → TNF inhibitor (or IL-17) if refractory — biologic entry: ASDAS ≥2.1 + failed ≥2 NSAIDs; TNFi preferred if recurrent uveitis/IBD, IL-17i if significant psoriasis; JAKi (tofacitinib/upadacitinib) after TNFi/IL-17i (ASAS-EULAR 2022)
Order set
- HLA-B27
- ESR/CRP
- SI joint MRI/X-ray
- PFTs if advanced
Criteria
AdmitFracture (rigid spine), cauda equina, acute uveitis
ICUSpinal cord injury
DischargeNSAIDs/biologic plan, physio, complication excluded
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- New neuro deficit
- Cauda equina
- Fracture (rigid spine)
Differentials
- Mechanical back pain
- DISH
- Reactive arthritis
Common mistakes
- Attributing inflammatory back pain to mechanical
- Missing uveitis
Disposition & follow-up
NSAIDs + physio; biologics if refractory.
Discharge package
MedicationsNSAIDs ± biologic
Follow-upRheumatology; physiotherapy
LifestyleExercise/posture program
Warning symptomsNew neuro deficit, eye pain/redness
💊 Treatment detail — doses & preparation
NaproxenNSAID
Dose500 mg BD with food (axSpA first-line; continuous use only if needed for symptom control)
Preparation250/500 mg tablets; add PPI if risk factors
MonitorRenal function, GI bleeding, BP; avoid in CKD/HF
Infliximabanti-TNF
Dose5 mg/kg IV at wk 0, 2, 6 then q8 wk
Preparation100 mg vial reconstitute, infuse over 2 h with observation
MonitorTB/hepatitis B screen first; infusion reactions; avoid live vaccines
📖 ASAS-EULAR axial SpAReviewed July 2026