How would you manage axial stiffness without pain in an elderly gentleman with a distant history of HLA-B27+ axial and peripheral spondyloarthritis, now with SI joint fusion, no peripheral arthritis, normal inflammatory markers, and no response to TNF inhibition?

Based on the history and lack of response to anti-TNF therapy, I suspect the patient does not currently have active inflammatory disease but likely sequalae of prior damage and degenerative spinal disease as a cause of his stiffness. A trial off of the biologic would help assess if the medication is at all effective, if there are no discernable changes, you could consider stopping this medication and treating conservatively.

The two most important points given here in the limited history are “no pain” and “normal inflammatory markers”. That changed my approach for aggressive management in this ‘elderly’ person. I would like to understand how this stiffness is affecting his daily lifestyle. Is this more of a prolonged morning stiffness or a day-long problem that affects his activities of daily living? Physical therapy combined with water-based exercises, yoga, and pilates would be my strong recommendation. As comment...

Further information is needed in order to properly determine what the "stiffness" means: inflammatory vs. non-inflammatory.

Certainly, in the absence of any clinical response, stopping the TNFi agent would be prudent; if there is worsening of symptoms, then perhaps it was actually working but not well enough. Dr. @Dr. First Last is certainly correct that lack of response is compatible with lack of inflammation.

I do not know what exactly elderly means; this is an editorial comment, not a fact. A...