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Subclinical Gut Inflammation SpA — SCE Rheumatology MCQ

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ModerateSpondyloarthropathySubclinical Gut Inflammation SpASCE Rheumatology

A 30-year-old man with axial spondyloarthritis has been receiving secukinumab for 14 months with good spinal response. Ileocolonoscopy for 3 months of persistent diarrhoea and abdominal pain shows patchy terminal ileal ulceration; biopsies demonstrate histologically active granulomatous inflammation, and gastroenterology review confirms Crohn's disease. Infection has been excluded. Which is the most appropriate targeted-therapy plan?

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

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Correct answer: D — Stop secukinumab and, jointly with gastroenterology, start a monoclonal TNF inhibitor with efficacy in both axial spondyloarthritis and Crohn's disease

Explanation lettering: D = shown as A · E = shown as B · B = shown as C · A = shown as D · C = shown as E

A is correct. Histology plus gastroenterology confirmation establishes active Crohn's disease, an extra-musculoskeletal manifestation that should drive biologic selection under the 2025 BSR axSpA guideline. IL-17A inhibition is ineffective in luminal Crohn's disease and is associated with new-onset or flaring IBD, so secukinumab should be stopped; a monoclonal anti-TNF (adalimumab or infliximab) treats both axial disease and Crohn's, chosen jointly with gastroenterology. B ignores a manifestation that alters class choice. C is wrong because IL-17 blockade failed in Crohn's trials and may worsen gut inflammation. D is a classic trap: etanercept, a soluble receptor fusion protein, is ineffective in Crohn's disease. E fails because methotrexate does not control axial disease and is not appropriate monotherapy here.

Reference: Zhao SS, Harrison SR, Thompson B, et al. The 2025 British Society for Rheumatology guideline for the treatment of axial spondyloarthritis with biologic and targeted synthetic DMARDs. Rheumatology (Oxford), 2025 — sections on extra-musculoskeletal manifestations (inflammatory bowel disease) and drug selection. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12107049/