What treatment strategies would you utilize in a patient with newly diagnosed HLA-B27+ axial spondyloarthritis (with active and chronic sacroiliitis on MRI) and recent diagnosis of MS that is well-controlled MS ocrelizumab given the need to avoid TNF inhibitors?

This is a very challenging scenario.

On one hand, TNFi are generally unsafe for MS due to demyelination risk, and on the other hand, anti-CD20 therapies for MS are linked to new AxSpA, but B-cell depletion might also benefit AxSpA. Thus, management requires specialized care in balancing both diseases, considering drug efficacy/safety, and prioritizing anti-IL-17 or JAK inhibitors for AxSpA while avoiding TNFi due to MS and carefully considering anti-CD20s.

For patients who develop or have AxSpA while on anti-CD20 therapy, the need to continue with anti-CD20 treatment should be balanced based on MS and AxSpA activity and a shared decision with Neurology.

A conservative idea to treat mild to moderate AxSpA in patients with highly active MS wh...