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Nonradiographic axial spondyloarthritis — ABIM Board MCQ

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HardRheumatology/Allergy/ImmunologyNonradiographic axial spondyloarthritisABIM Board

A 31-year-old man with MRI-confirmed axial spondyloarthritis has persistent active disease despite trials of two NSAIDs. He also has recurrent acute anterior uveitis but no inflammatory bowel disease. Which escalation is most appropriate?

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Correct answer: D — Start adalimumab after tuberculosis and hepatitis screening

The best answer is “Start adalimumab after tuberculosis and hepatitis screening”. Biologic therapy is appropriate after inadequate NSAID response even in nonradiographic axial disease. Recurrent uveitis favors a monoclonal TNF inhibitor, such as adalimumab or infliximab, over etanercept because the monoclonal agents better prevent ocular recurrence. Methotrexate does not reliably treat axial inflammation, and chronic systemic glucocorticoids have an unfavorable risk-benefit profile.

Reference: 2026 ACR Axial Spondyloarthritis Guideline Summary: https://rheumatology.org/press-releases/new-guidelines-advance-treatment-of-axial-spondyloarthritis-in-adults-and-youth