Case 1
Author: Mohamad Bittar, MD
A 45-year-old man with Crohn’s disease and low back pain is referred to you for a second opinion.
Timeline
2015: Patient was diagnosed with Crohn’s. Patient was placed on mesalamine which controlled his symptoms. Last major flare was in 2015.
2017: Patient started experiencing low back pain, associated with 1 hour of morning stiffness. Pain worsened with rest and improved with activity.
- Elevated CRP
- Pelvis x-ray was normal
- MRI of the pelvis demonstrated active sacroiliitis
- Patient was started on Adalimumab which greatly improved his symptoms.
2019: Patient gradually started experiencing recurrence of inflammatory back symptoms.
- On exam, mSchober was 3 cm (prior was 5 cm), there was tenderness to palpation of both SI joints and FABER was positive for SIJ pain bilaterally.
- BASDAI had increased from 3.0 prior to 6.0.
- Adalimumab level was undetectable and anti-adalimumab antibodies were elevated above assay.
2020: Patient was switched to Secukinumab 150mg subq every 4 weeks
2021: New patient visit with you.
- Has been on Secukinumab x 10 months
- Modest improvement in back symptoms, but still complains of ~45 minutes of morning stiffness and pain around the SI joints 2-3 days a week.
- Over the past 1-2 months, he started having intermittent abdominal pains, 4-5 loose bowel movements per day (up from 1-2), with some blood in the stools. No fevers or chills reported. No urinary symptoms.
- Colonoscopy demonstrated serpiginous and linear ulcers resulting in cobblestoning, with histology consistent with active Crohn’s disease
Which of the following would be the next most appropriate step in management?
- Increase Secukinumab dose to 300mg every 4 weeks
- Continue Secukinumab same dose, add sulfasalazine
- Discontinue Secukinumab, start Ustekinumab
- Discontinue Secukinumab, start Certolizumab
D. Discontinue Secukinumab, start Certolizumab
Per the 2019 ACR/SAA/SPARTAN treatment recommendations, TNFi monoclonal antibodies are the preferred agents over other biologics in AS patients with recurrent uveitis or inflammatory bowel disease (IBD) [1]. IL-17 inhibitors have been considered by experts to have a “disease aggravating effect” in IBD [2]. In this patient who developed an active IBD flare while on an IL-17 inhibitor, it is best to discontinue Secukinumab and start a TNF inhibitor. While Ustekinumab has shown benefit in peripheral spondyloarthritis, data from 3 placebo-controlled trials evaluating Ustekinumab in the treatment of axial spondyloarthritis did not demonstrate efficacy [3].
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References
- Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, Haroon N, Borenstein D, Wang R, Biehl A, Fang MA, Louie G, Majithia V, Ng B, Bigham R, Pianin M, Shah AA, Sullivan N, Turgunbaev M, Oristaglio J, Turner A, Maksymowych WP, Caplan L. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019 Oct;71(10):1599-1613. doi: 10.1002/art.41042. Epub 2019 Aug 22. PMID: 31436036; PMCID: PMC6764882.
- Bravo A, Kavanaugh A. Bedside to bench: defining the immunopathogenesis of psoriatic arthritis. Nat Rev Rheumatol. 2019 Nov;15(11):645-656. doi: 10.1038/s41584-019-0285-8. Epub 2019 Sep 4. PMID: 31485004.
- Deodhar A, Gensler LS, Sieper J, Clark M, Calderon C, Wang Y, Zhou Y, Leu JH, Campbell K, Sweet K, Harrison DD, Hsia EC, van der Heijde D. Three Multicenter, Randomized, Double-Blind, Placebo-Controlled Studies Evaluating the Efficacy and Safety of Ustekinumab in Axial Spondyloarthritis. Arthritis Rheumatol. 2019 Feb;71(2):258-270. doi: 10.1002/art.40728. Epub 2018 Dec 29. PMID: 30225992.
