Axial Spondyloarthritis: From Inflammatory Back Pain to Targeted Therapy

In this episode of MD Newsline, Dr. Joel Wright, a rheumatology fellow at UCLA, provides an in-depth, practical discussion on axial spondyloarthritis and related spondyloarthritides. Dr. Wright breaks down evolving disease definitions, diagnostic challenges, imaging interpretation, and modern treatment strategies, while emphasizing a holistic, patient-centered approach to care. The conversation highlights how early recognition and individualized therapy can significantly improve long-term outcomes.

Episode Highlights

Defining Axial vs. Peripheral Spondyloarthritis

Dr. Wright explains the modern classification of spondyloarthritis, distinguishing axial disease—which primarily affects the spine and sacroiliac joints—from peripheral spondyloarthritis and psoriatic arthritis. He discusses why the shift away from the term ankylosing spondylitis allows for earlier diagnosis before irreversible spinal fusion occurs.

Recognizing Red Flags Across Specialties

Inflammatory back pain remains the most important clinical clue, particularly pain that worsens at rest, improves with exercise, and is associated with prolonged morning stiffness. Dr. Wright also highlights extra-musculoskeletal signs—such as uveitis, psoriasis, and inflammatory bowel disease—that should prompt early referral to rheumatology.

Classification Criteria vs. Clinical Judgment

While ASAS classification criteria are useful for research, Dr. Wright emphasizes that real-world diagnosis relies on clinical expertise. Patients may not meet strict criteria early in the disease course, yet still warrant diagnosis and treatment based on symptoms, exam findings, labs, and imaging.

MRI Use and Common Diagnostic Pitfalls

MRI of the sacroiliac joints plays a central role in early detection, but Dr. Wright cautions against overreliance on imaging alone. Bone marrow edema can be seen in athletes, postpartum patients, or with aging, underscoring the importance of correlating MRI findings with clinical context.

Biomarkers and Emerging Research

HLA-B27, ESR, and CRP remain useful tools, though many patients have normal inflammatory markers. Dr. Wright discusses emerging biomarkers, including antibodies such as anti-CD74, and the need for more reliable tools to support earlier diagnosis.

Treatment Algorithms and Medication Selection

NSAIDs remain first-line therapy and may slow radiographic progression. For patients with inadequate response, Dr. Wright outlines escalation to biologics, including TNF inhibitors, IL-17 inhibitors, and JAK inhibitors—while tailoring choices based on comorbidities such as uveitis or inflammatory bowel disease.

Treat-to-Target and Monitoring

Early disease requires more frequent follow-up to assess response and adjust therapy. Dr. Wright explains realistic timelines for evaluating NSAIDs and biologics while balancing treat-to-target goals with clinic capacity.

The Role of Exercise and Non-Pharmacologic Care

Physical therapy, structured exercise, and low-impact activities such as swimming and cycling are foundational to care. Dr. Wright emphasizes the mental and physical benefits of movement, posture training, and holistic therapies alongside medication.

Managing Comorbidities and Special Populations

The discussion covers cardiovascular risk screening, adherence challenges in younger patients, biologic tapering in remission, pregnancy considerations, and care for older adults with established structural damage. Shared decision-making remains central across all scenarios.

Key Takeaway

Dr. Wright underscores that axial spondyloarthritis requires early recognition, thoughtful interpretation of imaging, and individualized treatment strategies. Combining pharmacologic therapy with exercise, multidisciplinary care, and patient education is essential to improving quality of life and preventing long-term disability.

Resources

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Connect with Dr. Joel Wright: Here