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Difficulty: EasyRheumatology and Immunology

A 24-year-old man comes to the clinic complaining of lower back pain that has progressively worsened over the past 7 months. He states that the pain is most severe when he wakes up in the morning and is associated with profound stiffness that lasts for about 2 hours. The discomfort noticeably improves after he goes for a jog or stretches, but it does not improve with rest. He has no history of trauma or recent infections. Vital signs are within normal limits. Physical examination reveals reduced forward flexion of the lumbar spine. An anteroposterior radiograph of the pelvis demonstrates bilateral sclerosis and joint space narrowing of the sacroiliac joints. Which of the following is the most appropriate initial pharmacotherapy for this patient's condition?

  1. Nonsteroidal anti-inflammatory drugsAnswer
  2. B
    Tumor necrosis factor-alpha inhibitors
  3. C
    Systemic corticosteroids
  4. D
    Acetaminophen
  5. E
    Intravenous broad-spectrum antibiotics

Answer

Nonsteroidal anti-inflammatory drugs are the first-line medical therapy for ankylosing spondylitis.
The patient's clinical presentation of chronic, insidious-onset lower back pain that is worse in the morning, improves with exercise, and is accompanied by radiographic evidence of sacroiliitis is highly characteristic of ankylosing spondylitis. For patients with active ankylosing spondylitis, continuous treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) is the most appropriate first-line pharmacologic therapy. NSAIDs are highly effective in reducing pain, decreasing morning stiffness, and improving overall mobility in these patients.

Step-by-Step Solution

1
Identify the primary clinical syndrome based on the history.
A young male with chronic lower back pain, severe morning stiffness, and improvement with physical activity but not with rest.
These classic features differentiate inflammatory back pain from mechanical back pain.
2
Interpret the radiographic findings.
Bilateral sclerosis and joint space narrowing of the sacroiliac joints (sacroiliitis).
Confirms the diagnosis of ankylosing spondylitis when combined with the clinical presentation of inflammatory back pain.
3
Determine the standard initial pharmacotherapy for this diagnosis.
Nonsteroidal anti-inflammatory drugs (NSAIDs).
Continuous use of NSAIDs is the established first-line treatment to reduce pain and stiffness in axial spondyloarthritis.

Key Concept

Ankylosing spondylitis is characterized by inflammatory back pain and sacroiliitis, and continuous NSAID therapy is the most appropriate initial pharmacologic treatment.
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Topics

Rheumatology and Immunology

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