#but then they said they can't because i'm on immunosuppressive drugs which makes it more complicated (fair)

[shinysteph]

Cannot sleep because kidneys hurt so bad!!!

[mcatmemoranda]

One of my pts has ankylosing spondylitis. He said he used to be treated for his symptoms with prednisone 20 mg, which was then tapered*. The treatment is NSAIDs. If that doesn't work, you can add a disease modifying antirheumatic drug (DMARD). Tx is basically: NSAIDs, DMARDS, PT, smoking cessation.

*According to UpToDate: In patients with axial SpA, there is an extremely limited role, if any, for the use of opioid analgesics. Systemic glucocorticoids (eg, prednisone) are ineffective for axial SpA in low to moderate doses and are not indicated. However, the pt can't take NSAIDs because he has kidney disease. So that makes sense. This is complex. I was reading through notes from his office visits. Some physicians think of and pick up things that others don't; but the diagnostic tests chosen are not the gold standard. So it just shows that nobody knows everything and it takes a team to take care of the pt. I care about this pt and have good rapport with him, so I want to help him feel good and be healthy.

From UpToDate:

The primary goals of management are to optimize short- and long-term health-related quality of life through relief of symptoms, maintenance of function, prevention of spinal complications, minimization of extraspinal and extraarticular manifestations and comorbidities, and maintenance of effective psychosocial functioning. Most patients benefit from care by an expert in rheumatologic disease, such as a rheumatologist; care should be coordinated with appropriate specialists, depending upon the clinical features; and active patient engagement in shared decision-making with their clinical team is an important element of care.

All patients with axial spondyloarthritis (SpA) should receive education about their disease and its management; counseling regarding smoking cessation, depression screening and psychosocial support, and physical therapy with instruction in home exercises.

In most patients with symptomatic axial SpA, we recommend a nonsteroidal antiinflammatory drug (NSAID) as initial therapy, rather than starting a disease-modifying antirheumatic drug (DMARD). Examples include naproxen (up to 500 mg twice daily) or ibuprofen (up to 800 mg three times daily), although any NSAID may be effective (table 1). Regardless of the NSAID used, the maximum dose is usually required, and the response should be assessed after a sustained dose on a daily basis for at least two to four weeks. In patients with an inadequate response, we switch to a second NSAID.

In patients with symptoms due to active axial SpA and an inadequate response to initial therapy with at least two NSAIDs consecutively, we suggest adding a tumor necrosis factor (TNF)-alpha inhibitor rather than treatment with NSAIDs alone. Any of the TNF inhibitors (eg, subcutaneous adalimumab 40 mg every other week or infliximab 5 mg/kg by intravenous infusion at zero, two, and six weeks followed by a maintenance dose of 5 mg/kg every eight weeks) is an acceptable option; the choice between drugs is based upon patient preferences regarding the route and frequency of administration, physician preference and experience, and regulatory and cost constraints. These biologics do not need to be used together with a conventional synthetic (cs) immunosuppressive agent such as methotrexate (MTX).

I'm assuming a rheumatologist would manage DMARD if the pt needs it.

The interleukin 17 (IL-17) inhibitors secukinumab and ixekizumab are reasonable alternatives to a TNF inhibitor as initial biologic therapy (for example, in case of concomitant psoriasis), although there is much more experience and evidence of long-term efficacy and safety with the TNF inhibitors.