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.
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) . IL-17 inhibitors have been considered by experts to have a “disease aggravating effect” in IBD . 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 .
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