Avoid initiating biological treatment in axial spondyloarthritis without clear signs of inflammation

Rationale:

Biological disease-modifying treatment (bDMARDs) should not be initiated in axial spondyloarthritis without significant bone marrow edema on MRI and/or elevated CRP. There are many causes of bone marrow edema on MRI, such as degeneration, trauma, and childbirth, so MRI findings must be assessed in the context of the clinical picture. 

References:

• Nasjonal prosedyre: Utredning, behandling og oppfølging av axial spondyloartritt ved Hilde Stray. https://legeforeningen.no/Fagmed/Norsk-revmatologisk-forening/Fagradets-innstillinger/Ferdige-norske-prosedyrer/
• 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. van der Heijde D, et al. Ann Rheum Dis 2017.
• Associations between spondyloarthritis features and MRI findings. B. Arnbak et al. Arthritis and Rheumatology 2016.
• Frequency and anatomic distribution of MRI features in the SI joints of young athletes. U. Weber et al. Arthritis Rheumatol. 2018.