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Treatment approach of seronegative spondyloarthritis
- Untreated disease may lead to irreversible structural damage and associated ↓ function
- Early physiotherapy beneficial
- Tight control of inflammation may improve outcomes (eg, in PsA; Lancet 2015;386:2489)
- NSAIDs: 1st line; rapidly ↓ stiffness and pain; prolonged, continuous administration may modify disease course but associated w/ GI and CV toxicity (Cochrane Database Syst Rev 2015;17:CD010952); may exacerbate IBD
- Intra-articular corticosteroids in mono- or oligoarthritis; limited role for systemic steroids, esp. for axial disease
- Conventional DMARDs (eg, MTX, SSZ, leflunomide):
- no efficacy for axial disease or enthesitis; may have a role in peripheral arthritis, uveitis, and extra-articular manifestations
- Anti-TNFs:
- effective for both axial and peripheral SpA, improves function and may slow progression of structural changes; adalimumab or infliximab preferred if eyes involved
- Anti-IL17A (secukinumab, ixekizumab):
- for both AS and axial and peripheral PsA (NEJM 2015;373:1329 & 2534; Lancet 2015;386:1137)
- Anti-IL12/23 (ustekinumab) and anti-IL23 (guselkumab)
- for both axial & peripheral PsA (Lancet 2020;395:1115) but not axial SpA (Arthritis Rheumatol 2019;71:258)
- PDE-4 inhibitor (apremilast):
- effective in PsA refractory to conventional DMARD or as first-line (Rheumatology 2018;7:1253); a/w GI side effects and wt loss
- JAK inhibitor:
- for conventional DMARD- or anti-TNF-resistant peripheral and/or axial SpA (NEJM 2017;377:1525 & 1537; 2021;384:1227)
- Other:
- Abx indicated in ReA if active GU infxn but not typically needed for uncomplicated enteric infx. Can consider prolonged abx for refractory Chlamydia ReA (Arthritis Rheum 2010;62:1298), but controversial.
- Involve ophtho if suspect eyes affected (may need steroid drops or intravitreal injection)
- Treat underlying IBD when appropriate