A 45-year-old man presents with inflammatory back pain for 6 months that improves with activity and worsens with rest. He reports morning stiffness lasting 90 minutes. X-ray of the sacroiliac joints reveals bilateral grade 3 sacroiliitis with erosions and sclerosis. HLA-B27 is positive. Which of the following is the most appropriate initial pharmacotherapy?
- A Oral prednisone 40 mg daily
- B Naproxen 500 mg twice daily with PPI cover ✓
- C Methotrexate 15 mg weekly
- D Sulfasalazine 1 g twice daily
Correct answer: B. Naproxen 500 mg twice daily with PPI cover
Explanation
The patient has ankylosing spondylitis based on inflammatory back pain, bilateral sacroiliitis on imaging, and HLA-B27 positivity. First-line treatment is a nonsteroidal anti-inflammatory drug (NSAID). Continuous NSAID use may slow radiographic progression. Sulfasalazine is used for peripheral arthritis but is ineffective for axial disease. Methotrexate has limited evidence in axial spondyloarthritis. TNF inhibitors are reserved for NSAID-refractory cases.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.