What do you try in patients with IBD-related spondyloarthritis with predominantly axial symptoms who are refractory to TNF inhibitors?

Treating these patients is challenging. It's always good to circle back to first-line therapy recommendations for axial spondyloarthritis and ensure that patients are doing physical therapy or exercise daily. Patients whose IBD is in remission may be able to add a COX-2 selective NSAID (celecoxib), which has some data on safety among IBD patients. This recommendation must be made only if the patient's gastroenterologist finds it reasonable.

If TNF-inhibitor, exercise, and a COX-2 selective NSAID are not sufficient to control axial disease, then a JAK inhibitor may be considered (off label for axial spondyloarthritis). Tofacitinib has US FDA approval for treatment of ulcerative colitis (but not Crohn's disease). Data from a phase II trial in...