From the Guidelines
Ankylosing spondylitis should be treated with a multifaceted approach, starting with non-pharmacological interventions and NSAIDs as first-line medications, and considering TNF inhibitors or IL-17 inhibitors for patients with inadequate response to NSAIDs, as recommended by the most recent guidelines 1.
Diagnosis
Ankylosing spondylitis is diagnosed through a combination of clinical evaluation, imaging studies, and laboratory tests. Diagnosis typically involves assessing symptoms like chronic low back pain lasting more than three months that improves with exercise and worsens with rest, limited spinal mobility, and morning stiffness. Radiographic findings include sacroiliitis on X-rays or MRI, and blood tests may show elevated inflammatory markers (ESR, CRP) and the presence of HLA-B27 genetic marker in about 90% of patients.
Treatment
Treatment follows a multifaceted approach starting with non-pharmacological interventions like:
- Regular exercise
- Physical therapy
- Posture training First-line medications include NSAIDs such as:
- Naproxen (500mg twice daily)
- Indomethacin (25mg 2-3 times daily) for pain and inflammation For patients with inadequate response to NSAIDs, TNF inhibitors are recommended, including adalimumab (40mg every other week), etanercept (50mg weekly), or infliximab (5mg/kg at weeks 0,2,6, then every 6-8 weeks) 1. IL-17 inhibitors like secukinumab (150mg weekly for 5 weeks, then monthly) are alternative biologics. Conventional DMARDs such as sulfasalazine (1-3g daily) may help peripheral joint symptoms but are less effective for axial disease.
Monitoring and Screening
Regular monitoring for disease progression and treatment response is essential, as is screening for extra-articular manifestations like:
- Uveitis
- Inflammatory bowel disease
- Psoriasis The goal of treatment is to reduce pain, maintain spinal mobility, prevent deformities, and improve quality of life, as supported by the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations 1.
From the FDA Drug Label
1.3 Ankylosing Spondylitis COSENTYX is indicated for the treatment of adult patients with active ankylosing spondylitis (AS). The primary endpoint was the percentage of patients who achieved an ASAS20 response at Week 16. In AS1, patients treated with 150 mg COSENTYX demonstrated greater improvements in ASAS20 and ASAS40 responses compared to patients treated with placebo at Week 16
The diagnosis of ankylosing spondylitis is not directly addressed in the provided drug labels. The treatment of ankylosing spondylitis with secukinumab (SQ) is indicated for adult patients with active ankylosing spondylitis (AS) 2, 2.
- Key points:
- Secukinumab (SQ) is used to treat active ankylosing spondylitis.
- The primary endpoint in the study was the percentage of patients who achieved an ASAS20 response at Week 16.
- Patients treated with 150 mg secukinumab demonstrated greater improvements in ASAS20 and ASAS40 responses compared to patients treated with placebo at Week 16.
From the Research
Diagnosis of Ankylosing Spondylosis
- The diagnosis of ankylosing spondylosis can be made using magnetic resonance imaging to visualize the inflammatory changes in the sacroiliac joint and the axial spine 3.
- The use of tumor necrosis factor blocking agents has been shown to be highly efficacious in reducing spinal inflammation and possibly in slowing radiographic progression 3.
Treatment of Ankylosing Spondylosis
- Tumor necrosis factor-alpha inhibitors, such as adalimumab, etanercept, golimumab, and infliximab, have been shown to be effective in reducing spinal inflammation and improving clinical symptoms in patients with ankylosing spondylitis 4.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage inflammatory symptoms in patients with ankylosing spondylitis, but they have a significant side effect profile and may not be effective for all patients 5.
- The Chinese Rheumatology Association has developed standardized recommendations for the diagnosis and treatment of ankylosing spondylitis, including the use of NSAIDs, biological agents, and traditional disease-modifying anti-rheumatic drugs 6.
- There is ongoing research into the potential disease-modifying effects of NSAIDs and biologics in axial spondyloarthritis, but the current evidence is inconclusive 7.
Management of Ankylosing Spondylosis
- The management of ankylosing spondylosis typically involves a combination of pharmacological and non-pharmacological interventions, including physical therapy and lifestyle modifications.
- The use of anti-TNF agents has been shown to improve clinical symptoms and reduce spinal inflammation in patients with ankylosing spondylitis, but the long-term effects on radiographic progression are unclear 4.
- NSAIDs may have potential disease-modifying effects in axial spondyloarthritis, but further research is needed to confirm this 7.