From the Guidelines
Spondylitis treatment should prioritize nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, followed by biologic medications such as TNF 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 Overview
Spondylitis is a chronic inflammatory disease that affects the vertebrae in the spine, and its treatment aims to reduce pain and inflammation, maintain posture and spinal mobility, and prevent disease progression.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen (500mg twice daily) or indomethacin (25mg 2-3 times daily) are recommended as first-line therapy to reduce pain and inflammation 1.
- For patients who don't respond adequately to NSAIDs, biologic medications such as TNF inhibitors (adalimumab 40mg every other week or etanercept 50mg weekly by subcutaneous injection) are often prescribed 1.
Additional Recommendations
- Physical therapy is essential, focusing on exercises that maintain posture, spinal mobility, and chest expansion 1.
- A regular exercise routine including swimming, walking, or stretching for 30 minutes daily helps maintain flexibility and posture 1.
- Patients should avoid smoking as it worsens disease progression and adopt proper sleeping positions on a firm mattress with minimal pillows to maintain spinal alignment 1.
- Heat therapy can provide temporary relief for stiff joints 1.
Disease Management
- Treatment of spondylitis should be tailored according to the current manifestations of the disease, level of symptoms, and prognostic indicators 1.
- Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging, all according to the clinical presentation, as well as the ASAS core set 1.
- The frequency of monitoring should be decided on an individual basis depending on symptoms, severity, and drug treatment 1.
From the FDA Drug Label
1.4 Ankylosing Spondylitis Enbrel is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis (AS). The answer to the question about Spondylitis is that Etanercept (Enbrel) is indicated for reducing signs and symptoms in patients with active Ankylosing Spondylitis (AS) 2.
- Key Points:
- Indication: Ankylosing Spondylitis (AS)
- Drug: Etanercept (Enbrel)
- Dosage: 50 mg weekly (for adult patients) 2
From the Research
Definition and Symptoms of Spondylitis
- Spondylitis, specifically ankylosing spondylitis (AS), is a systemic inflammatory rheumatic disease involving spinal and sacroiliac joints, characterized by back pain, stiffness, and discomfort 3.
- The disease can lead to enthesopathy, sacroiliac joint pain, and spinal ankylosis, affecting the patient's quality of life 3.
Treatment Options for Spondylitis
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are the main drug group used in AS, reducing pain and stiffness in most patients 3, 4, 5.
- NSAIDs can be divided into nonselective and cyclo-oxygenase (COX)-2-selective NSAIDs, both of which have been found to be effective in relieving pain and improving physical function in patients with AS 6, 7.
- Other treatment options include:
- Analgesics, muscle relaxants, and low-dose corticosteroids as adjuvant therapy 3.
- Disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine, which has been shown to be effective in patients with peripheral disease involvement 3, 6.
- Anti-tumor necrosis factor (TNF)-alpha agents, which have been found to be effective in treating both peripheral and axial symptoms in patients with AS 6.
- Local injection of corticosteroids for enthesopathy and sacroiliac joint pain 3.
- Patient education, rest, physical exercise, and physiotherapy to reduce stiffness and spinal ankylosis 3.
Efficacy and Safety of NSAIDs
- NSAIDs have been found to be effective in reducing pain severity, improving patients' global assessment of disease activity, and achieving an Assessment in Ankylosing Spondylitis 20% response (ASAS20) 7.
- However, NSAIDs can cause gastrointestinal toxicity, and patients treated with diclofenac and naproxen have a higher risk of gastrointestinal events than those taking placebo 7.
- Etoricoxib has been ranked as the most efficacious treatment for patients with AS, with significant improvements in pain severity, patients' global assessment of disease activity, and ASAS20 7.