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First-Line SpA Treatment — SCE Rheumatology MCQ

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EasySpondyloarthropathyFirst-Line SpA TreatmentSCE Rheumatology

A 42-year-old man with seronegative SpA presents with inflammatory low back pain and bilateral buttock pain alternating between sides. His HLA-B27 is positive. MRI shows bilateral sacroiliac bone marrow oedema. He fulfils ASAS criteria for axial SpA. According to BSR 2025 what is the first-line pharmacological treatment?

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Correct answer: E — Full-dose NSAID (e.g. Naproxen 500 mg BD or Etoricoxib 90 mg daily) as first-line pharmacological therapy; at least 2 different NSAIDs should be tried at full therapeutic dose for a minimum of 2-4 weeks each before considering escalation to biologic therapy

BSR 2025 axSpA guidelines and EULAR/ASAS 2022 recommendations establish NSAIDs as first-line pharmacological therapy for axial SpA. At least 2 different NSAIDs at full therapeutic doses should be tried for a minimum of 2-4 weeks each (to allow full anti-inflammatory effect) before the patient is considered to have failed NSAIDs. Failure of 2 NSAIDs is typically required before escalation to biologic or targeted synthetic DMARD therapy. csDMARDs (Methotrexate Sulfasalazine) have NO efficacy for axial disease. Glucocorticoids have very limited role in axSpA (short-term local injections for peripheral involvement).

Reference: BSR 2025 axSpA guidelines; EULAR/ASAS 2022