Medicine – Treatment of Spondyloarthropathies

The spondyloarthropathies, now commonly referred to as spondyloarthritis (SpA), are a group of inflammatory rheumatic diseases that predominantly affect the spine, sacroiliac joints, peripheral joints, and entheses. Management aims to reduce pain and inflammation, maintain mobility and posture, preserve physical function, and prevent structural complications. Treatment depends on whether the disease is predominantly axial or peripheral and on the severity of the patient’s symptoms.

1. Physiotherapy

Physiotherapy and regular exercise are fundamental components of treatment, particularly in patients with axial spondyloarthritis or ankylosing spondylitis. Exercise programmes are designed to maintain spinal mobility, flexibility, muscle strength, and good posture. Stretching and range-of-motion exercises can help reduce stiffness and prevent progressive loss of movement. Breathing exercises may also be useful for maintaining chest expansion when the thoracic spine and costovertebral joints are affected.

2. Local Steroid Injections

Local corticosteroid injections may be useful when inflammation is confined to a particular peripheral joint or enthesis. Injection directly into the affected area can reduce local pain, swelling, and inflammation while limiting the systemic adverse effects associated with prolonged oral corticosteroid therapy. Repeated injections into the same site should generally be used cautiously.

3. Non-Steroidal Anti-Inflammatory Drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used as initial pharmacological treatment for pain and stiffness, especially in axial spondyloarthritis. They reduce inflammation and can improve back pain, morning stiffness, and overall mobility. Treatment should be individualised because prolonged NSAID use can produce gastrointestinal, renal, and cardiovascular adverse effects.

4. Systemic Corticosteroids

Systemic corticosteroids can suppress inflammation rapidly and may occasionally be used for severe inflammatory manifestations or particular extra-articular complications. However, prolonged systemic steroid treatment is generally not preferred for predominantly axial disease because of limited long-term benefit and the considerable adverse effects associated with chronic corticosteroid exposure.

5. Sulfasalazine

Sulfasalazine is a conventional disease-modifying antirheumatic drug that can be useful in patients with persistent peripheral arthritis associated with spondyloarthritis. It has considerably less benefit for inflammation that is predominantly confined to the spine and sacroiliac joints. Adverse effects include gastrointestinal disturbance, skin reactions, liver abnormalities, cytopenias, and reversible reduction in sperm count.

6. Methotrexate

Methotrexate is another conventional disease-modifying antirheumatic drug that may be considered in selected patients with significant peripheral joint involvement. Like sulfasalazine, it has little established benefit for purely axial manifestations. Patients receiving methotrexate require monitoring for important adverse effects, particularly hepatotoxicity and bone marrow suppression.

Modern treatment of persistently active spondyloarthritis may also involve biologic or targeted therapies, particularly when symptoms remain inadequately controlled despite NSAIDs and appropriate non-pharmacological management. These include agents targeting TNF or IL-17, with treatment selected according to the type of spondyloarthritis and associated manifestations.

7. Antibiotics

Antibiotics are not routine treatment for most forms of spondyloarthritis. They should be used when there is an identifiable active bacterial infection requiring antimicrobial therapy. This is particularly relevant when an infection has triggered reactive arthritis. Treating the acute infection is important, although antibiotic therapy does not necessarily eliminate established joint inflammation once reactive arthritis has developed.

Key Treatment Principle

Management of spondyloarthritis combines regular exercise and physiotherapy with appropriate anti-inflammatory treatment. NSAIDs are particularly useful for axial symptoms, while sulfasalazine or methotrexate may have a role in peripheral arthritis. Local steroid injections can control focal inflammation, antibiotics are reserved for appropriate active infections, and biologic or targeted therapy may be required for persistently active disease.