What are the recommended management options for ankylosing spondylitis?

From the Guidelines

Management of ankylosing spondylitis requires a comprehensive approach combining non-pharmacological and pharmacological interventions, with the primary goal of reducing symptoms, maintaining spinal flexibility, and preventing disease complications, as recommended by the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 1.

Key Components of Management

• Regular physical therapy and exercise to maintain spinal mobility and posture
• NSAIDs, such as naproxen (500mg twice daily) or indomethacin (25mg three times daily), as first-line treatment for pain and inflammation control
• TNF inhibitors, like adalimumab (40mg subcutaneously every other week) or etanercept (50mg subcutaneously weekly), or IL-17 inhibitors, such as secukinumab (150mg subcutaneously weekly for five weeks, then monthly), if NSAIDs provide inadequate relief after 2-4 weeks of consistent use
• Conventional DMARDs, like methotrexate and sulfasalazine, may have limited effectiveness for axial symptoms but can help peripheral joint involvement

Patient Education and Monitoring

• Patient education about maintaining proper posture, smoking cessation, and regular monitoring for extra-articular manifestations (uveitis, inflammatory bowel disease) are essential components of management
• Regular monitoring of disease activity and adjustment of treatment as needed to achieve optimal outcomes

Treatment Recommendations

• The 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommends treatment with NSAIDs over no treatment with NSAIDs, and conditional recommendation for treatment with TNF inhibitors or IL-17 inhibitors in patients with active AS despite treatment with NSAIDs 1
• The 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis also provides guidance on the use of TNF inhibitors and IL-17 inhibitors in patients with axSpA 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).

2.3 Recommended Dosage in Adult Patients with Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, and Plaque Psoriasis Enbrel is administered by subcutaneous injection (Table 1). Table 1 Recommended Dosage for Adult Patients with RA, AS, PsA and PsO Patient PopulationRecommended Dosage Adult RA, AS, and PsA50 mg weekly

The recommended management option for Ankylosing Spondylitis (AS) is Etanercept (Enbrel) at a dosage of 50 mg weekly administered by subcutaneous injection 2.

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

2.1 Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis The recommended subcutaneous dosage of HUMIRA for adult patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) is 40 mg administered every other week

Another recommended management option for Ankylosing Spondylitis (AS) is Adalimumab (HUMIRA) at a dosage of 40 mg every other week administered by subcutaneous injection 3.

Key Points:

• Etanercept (Enbrel): 50 mg weekly
• Adalimumab (HUMIRA): 40 mg every other week
• Both are administered by subcutaneous injection.

From the Research

Management Options for Ankylosing Spondylitis

The management of ankylosing spondylitis (AS) involves a combination of non-pharmacological and pharmacological interventions. The following are some of the recommended management options:

• Non-pharmacological interventions:
  • Physical therapy: Individualized home exercise programs or supervised exercise programs can improve spinal mobility and physical function 4.
  • Patient education: Educating patients about the disease and its management can help maintain function and improve outcomes 5.
• Pharmacological interventions:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs can help reduce symptoms such as pain and stiffness 6, 5.
  • Tumor necrosis factor (TNF) alpha inhibitors: Biologics such as infliximab, etanercept, and adalimumab can improve spinal pain, function, and inflammatory biomarkers in patients with AS 7, 6, 5, 8.
  • Coxibs: Coxibs, a type of NSAID, can also be used to treat symptoms of AS 5.
• Other interventions:
  • Balneotherapy: Balneotherapy, or spa therapy, may be beneficial in improving symptoms of AS, especially when combined with exercise therapy 4.
  • Sulfasalazine: Sulfasalazine may be used as a second-line treatment for AS, especially in patients with peripheral arthritis 6.

Treatment Goals

The goal of treatment for AS is to reduce symptoms, improve function, and maintain quality of life. Treatment should be individualized based on the patient's specific needs and disease severity.

Monitoring and Follow-up

Regular monitoring and follow-up are essential to assess the effectiveness of treatment and adjust the treatment plan as needed. This may include regular assessments of pain, stiffness, spinal mobility, and physical function, as well as monitoring for potential side effects of medications.