The Skill Checkup series provides a short, interactive case study that highlights the most important guidelines- and research-based data to guide the practice of a physician.

A 44-year-old male living in the US with an history of axial Spondyloarthritis (SpA) suffers from the presence of moderate or severe lower back discomfort. This patient was first diagnosed as having axial SPA about 2 years ago. The first line treatment was naproxen, with a dose of 1000 mg/d. However, the patient was still symptomatic. In the last 20 months, he’s been treated with second-line etanercept at 50 mg/week. While the treatment was initially efficient, today at the visit, the patient is complaining of lower back pain that has become more severe in the past three months. He says the fact that back pain is most severe in the morning and often awakes him at late at night due to its intensity. He also experiences morning neck and back stiffness lasting for about one hour, along with severe exhaustion throughout the entire day, which hinders his ability to perform his position as foreman of construction.

The patient’s height is 5 feet 11 inches (1.8 meters) in height and weighs 178 lbs (80.74 kg BMI 24.8).

There are no signs of abnormality on physical exam. Vital signs are normal limits. Patients have an ankylosing spondylitis disease activity Score (ASDAS) that is 2.2. MRI uncovers inflammation in joint sacroiliacs.