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Axial PsA Treatment — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyAxial PsA TreatmentSCE Rheumatology

A 48-year-old woman with psoriatic arthritis has 9 months of inflammatory back pain and early-morning spinal stiffness lasting 90 minutes. MRI of the spine and sacroiliac joints shows active bone-marrow oedema at both sacroiliac joints. Her BASDAI is 6.2 with a spinal pain score of 7/10 and CRP is 22 mg/L. Peripheral joint counts are normal and her psoriasis is minimal on methotrexate 20 mg weekly, which she tolerates well. She has completed supervised spinal physiotherapy and adequate 4-week trials of two different NSAIDs at maximum tolerated doses without benefit. She has no inflammatory bowel disease, no uveitis and no contraindication to immunosuppression. What is the most appropriate treatment escalation?

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

Reveal the answer and explanation

Correct answer: C — Start a TNF inhibitor or an IL-17 inhibitor

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

This is objectively active axial disease (inflammatory back pain, MRI sacroiliitis, raised CRP, BASDAI 6.2) that has failed physiotherapy and two adequate NSAID trials, so escalation is to a biologic: a TNF inhibitor or an IL-17 inhibitor, in line with BSR axSpA guidance and EULAR PsA recommendations (a JAK inhibitor is an alternative but is not offered). Conventional synthetic DMARDs lack demonstrated efficacy in the axial domain: sulfasalazine and leflunomide (options A, D) may help peripheral arthritis only, and leflunomide would also risk losing peripheral/skin control. Hydroxychloroquine (C) has no role and may flare psoriasis. Escalating methotrexate to 30 mg weekly (E) exceeds usual practice, adds toxicity and still does not treat axial inflammation. With no IBD or uveitis, both TNF and IL-17 inhibition are acceptable; coexisting Crohn's disease would favour a monoclonal TNF inhibitor over IL-17 blockade.

Reference: British Society for Rheumatology. The 2025 BSR guideline for the treatment of axial spondyloarthritis with biologic and targeted synthetic DMARDs (Rheumatology, 2025) — recommendations on b/tsDMARD initiation after inadequate NSAID response and choice by extra-musculoskeletal manifestations. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12107049/