From the Guidelines
Ankylosing spondylitis should be treated with a combination of non-pharmacological and pharmacological approaches, with non-steroidal anti-inflammatory drugs (NSAIDs) as the first-line medication, followed by biologics such as TNF inhibitors or IL-17 inhibitors for patients who don't respond adequately to NSAIDs, as recommended by the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 1.
Treatment Approach
The treatment approach for ankylosing spondylitis typically involves a combination of non-pharmacological and pharmacological approaches.
- Non-pharmacological approaches include physical therapy, focusing on posture training, breathing exercises, and spine mobility, as well as regular exercise, particularly swimming and stretching, to help maintain flexibility and posture.
- Pharmacological approaches include the use of NSAIDs, such as naproxen (500mg twice daily) or indomethacin (25mg 2-3 times daily), as first-line medications to reduce pain and inflammation.
Biologics
For patients who don't respond adequately to NSAIDs, biologics such as TNF inhibitors (adalimumab 40mg every other week or etanercept 50mg weekly) or IL-17 inhibitors (secukinumab 150mg monthly after loading doses) are recommended, as supported by the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 1.
Disease Monitoring
Disease monitoring should include periodic X-rays or MRIs to assess disease progression, as well as regular assessments of the patient's symptoms and quality of life.
Key Recommendations
The key recommendations for the treatment of ankylosing spondylitis include:
- Treatment with NSAIDs over no treatment with NSAIDs 1
- Treatment with TNFi over no treatment with TNFi for patients who don't respond adequately to NSAIDs 1
- Treatment with secukinumab or ixekizumab over no treatment with secukinumab or ixekizumab for patients who don't respond adequately to NSAIDs 1
- Against treatment with systemic glucocorticoids 1
From the FDA Drug Label
1.3 Ankylosing Spondylitis COSENTYX is indicated for the treatment of adult patients with active ankylosing spondylitis (AS).
- Indication: Secukinumab (SQ) is indicated for the treatment of adult patients with active ankylosing spondylitis (AS).
- The recommended dosage for ankylosing spondylitis is not explicitly stated in the provided drug label, but it is mentioned that the effectiveness of intravenous COSENTYX in the treatment of adult patients with active AS was extrapolated from the established effectiveness of subcutaneous COSENTYX in adult patients with active AS based on pharmacokinetic exposure.
- In the AS1 study, patients treated with 150 mg COSENTYX demonstrated greater improvements in ASAS20 and ASAS40 responses compared to patients treated with placebo at Week 16.
- The ASAS20 response criteria include patient global assessment of disease activity, total spinal pain, BASFI, and inflammation.
- Clinical response was significant in patients treated with COSENTYX, with improvements in disease activity measures compared to placebo at Week 16 and Week 52 2.
From the Research
Treatment Options for Ankylosing Spondylitis
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for ankylosing spondylitis (AS) due to their rapid efficacy on inflammatory symptoms 3, 4, 5, 6
- NSAIDs can reduce pain, stiffness, and discomfort in patients with AS, but their long-term effects on the disease process are still unknown 7, 3
- The use of NSAIDs should be tailored to the individual patient, with consideration of their efficacy, safety, and potential side effects, such as gastrointestinal and renal toxicity 7, 3, 5
Disease Management
- Sulfasalazine is a disease-modifying drug that can suppress disease activity in AS, particularly in patients with high disease activity, peripheral arthritis, and short disease duration 7
- Analgesics and muscle relaxants can be used to manage pain and stiffness in patients with AS, especially those with longstanding disease refractory to NSAIDs 7
- Local injections of corticosteroids can be used to manage peripheral arthritis and enthesopathy in patients with AS 7
Special Considerations
- In patients with AS complicated by psoriasis or inflammatory bowel disease, treatment should be tailored to manage both conditions simultaneously 7
- In juvenile patients with AS, aspirin and NSAIDs can be used, but careful monitoring is necessary to prevent Reye's syndrome and gastric irritation 7
- During pregnancy and lactation, ibuprofen may be a preferred NSAID for managing AS due to its relatively safe profile 7
Recent Developments
- Tumor necrosis factor-α inhibitors have revolutionized the treatment of AS, particularly in patients with inadequate response to NSAIDs 4, 6
- Network meta-analysis has compared the efficacy and safety of different NSAIDs in patients with AS, revealing that all NSAIDs are effective in reducing pain severity, but with varying safety profiles 5