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Ankylosing Spondylitis — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyAnkylosing SpondylitisSCE Rheumatology

A 30-year-old man has radiographic axial spondyloarthritis. After adequate trials of two NSAIDs at maximum tolerated dose over 3 months, his BASDAI is 5.8 and his spinal pain visual analogue scale is 6.0 cm. He also has extensive scalp and trunk plaque psoriasis that has responded inadequately to methotrexate and phototherapy. He has never had inflammatory bowel disease or acute anterior uveitis, and has no history of demyelination, heart failure or latent tuberculosis. He works offshore and cannot attend hospital for intravenous infusions. In line with the 2025 British Society for Rheumatology axial spondyloarthritis guideline, which single first-line targeted therapy is most likely to control both his axial disease and his skin disease?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Secukinumab

Secukinumab is correct. He meets UK thresholds for targeted therapy (BASDAI and spinal pain VAS both >4 after two NSAIDs). BSR 2025 advises selecting the b/tsDMARD by extra-musculoskeletal manifestations: IL-17A inhibitors have high-level efficacy in both axial spondyloarthritis and severe plaque/scalp psoriasis that has failed systemic and phototherapy, and are acceptable here because he has no IBD (where IL-17 blockade can provoke flares) and no uveitis (where a monoclonal TNF inhibitor would be preferred). Infliximab is an effective monoclonal TNF inhibitor for skin and axial disease but is intravenous, which he cannot access. Etanercept treats axial disease but is the weakest listed option for extensive psoriasis and does not protect against uveitis or IBD. Apremilast helps psoriasis but has no proven axial efficacy; sulfasalazine acts only on peripheral arthritis.

Reference: Zhao SS, Harrison SR, Thompson B, et al. Executive Summary: The 2025 British Society for Rheumatology guideline for the treatment of axial spondyloarthritis with biologic and targeted synthetic DMARDs. Rheumatology (Oxford) 2025 — sections on treatment initiation and b/tsDMARD choice in extra-musculoskeletal manifestations. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12107059/