What is the management and treatment of ankylosing spondylitis?

From the Guidelines

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis characterized by sacroiliitis, enthesitis, and a marked propensity for sacroiliac joint and spinal fusion, and its management involves a combination of non-pharmacological and pharmacological approaches. The goals of treatment are to reduce symptoms, maintain spinal flexibility and normal posture, reduce functional limitations, maintain work ability, and decrease disease complications 1.

Non-Pharmacological Approaches

• Physical therapy and regular exercise are foundational treatments, focusing on posture training, stretching, and strengthening exercises to maintain spinal mobility and function.
• Patient education on proper posture, exercise, and stress management is also crucial.

Pharmacological Approaches

• First-line medications include nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (500mg twice daily) or indomethacin (25-50mg 2-3 times daily) to reduce pain and inflammation.
• For patients who don't respond adequately to NSAIDs, tumor necrosis factor (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) 2.
• Alternative biologics include IL-17 inhibitors like secukinumab (150mg weekly for 5 weeks, then monthly) or ixekizumab.
• Conventional disease-modifying antirheumatic drugs (DMARDs) like sulfasalazine (2-3g daily) may help with peripheral joint symptoms but are less effective for axial disease.

Other Considerations

• Pain management may include short-term use of muscle relaxants or local corticosteroid injections for specific painful areas.
• Surgery is reserved for severe cases with significant deformity or joint damage.
• Regular monitoring of disease activity and treatment response is essential, as is addressing comorbidities like osteoporosis, cardiovascular disease, and eye inflammation (uveitis) 3.

The most recent and highest quality study, published in 2019, provides updated recommendations for the treatment of AS and nonradiographic axial spondyloarthritis, emphasizing the use of NSAIDs, TNF inhibitors, and IL-17 inhibitors, as well as the importance of physical therapy and patient education 2.

From the FDA Drug Label

1. 4 Ankylosing Spondylitis HUMIRA is indicated for reducing signs and symptoms in adult patients with active ankylosing spondylitis.

1. 4 Ankylosing Spondylitis Enbrel is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis (AS).

Definition and Treatment of Ankylosing Spondylitis: Ankylosing spondylitis is a condition characterized by active symptoms that can be reduced with treatment.

• The management and treatment of ankylosing spondylitis involves reducing signs and symptoms in adult patients.
• Medications such as adalimumab (HUMIRA) and etanercept (Enbrel) are indicated for this purpose.
• The recommended dosage for adult patients with ankylosing spondylitis is 40 mg of HUMIRA administered every other week, or 50 mg of Enbrel administered weekly 4, 5.

From the Research

Definition of Ankylosing Spondylitis

• Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease that primarily affects the vertebral column and sacroiliac joints 6.
• It is characterized by extensive remodeling of the spinal axis via ligamentous ossification, vertebral joint fusion, osteoporosis, and kyphosis, resulting in a weakened vertebral column with increased susceptibility to fractures and spinal cord injury (SCI) 6.

Management and Treatment of Ankylosing Spondylitis

• The treatment of AS includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to manage inflammatory symptoms, although they may have a significant side effect profile 7.
• Tumor necrosis factor-alpha (TNF-alpha) inhibitors, such as adalimumab, etanercept, golimumab, and infliximab, have been shown to improve clinical symptoms in the treatment of AS, with a high quality of evidence 8.
• The use of TNF-alpha inhibitors has been associated with an increased risk of withdrawals due to adverse events, although the absolute increase in harm is small 8.
• In patients with stable AS receiving TNFi, the continued use of NSAIDs has been found to have no additional benefit in controlling disease activity, and withdrawal of NSAIDs may be preferable due to the risk of toxicity of long-term NSAID use 9.
• The pathogenesis of AS is complex and involves immune cells and innate cytokines, including human leukocyte antigen (HLA)-B27 and the interleukin-23/17 axis, although the exact mechanisms remain unclear 10.

Key Considerations

• The management of AS requires a comprehensive approach, taking into account the potential benefits and risks of different treatment options 8, 7, 9.
• Patients with AS should be closely monitored for disease activity and adverse events, and treatment should be tailored to individual needs 8, 9.
• Further research is needed to fully understand the pathogenesis of AS and to develop more effective and targeted treatments 10.