How would you approach treatment of active axial spondyloarthritis refractory to NSAID in a patient with concurrent autoinflammatory disease on long-term anti-IL-1 therapy?

This is a difficult situation indeed. I would certainly maximize the use of NSAIDs, physical therapy, sulfasalazine for peripheral arthritis/enthesitis, etc. Then I would discuss with the patient the pros and cons of the combination therapy of JAK inhibitor with IL-1 inhibitor. With shared decision ...

I would treat them as a patient with AxSpA based on our expert-developed and well-established treatment guidelines. IL-1 biologics have very little impact on pathways that fight infectious agents, proven by their use in studies in patients with sepsis.

I'd start on TNFi, IL-17, IL-12/23 biologic, or...

I completely agree with Atul that it is a very difficult clinical solution. One option is switching to a JAK inhibitor as recommended by him. Combining anti TNF inhibitors with IL- 1 inhibitor is another option but getting both approved by insurance is sometimes impossible.