What is the treatment approach for ankylosing spondylitis, including management of the microbiome?

From the Guidelines

The treatment approach for ankylosing spondylitis (AS) involves a combination of medication, physical therapy, and lifestyle modifications, with emerging interest in microbiome management, and according to the most recent guidelines, the first-line treatment should include nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy, with biologic medications targeting tumor necrosis factor (TNF) or IL-17 inhibitors considered for patients who do not respond adequately to NSAIDs 1. The treatment of AS typically starts with NSAIDs such as naproxen (500mg twice daily) or indomethacin (25mg 2-3 times daily) to reduce pain and inflammation. For patients who don't respond adequately to NSAIDs, biologic medications targeting tumor necrosis factor (TNF) 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). Alternatively, IL-17 inhibitors like secukinumab (150mg weekly for 5 weeks, then monthly) can be effective. Regular physical therapy focusing on posture, spinal mobility, and breathing exercises is crucial for maintaining function. Regarding microbiome management, while still investigational, approaches include increasing dietary fiber (25-30g daily), incorporating probiotics (particularly Lactobacillus and Bifidobacterium strains), and reducing processed foods. These dietary changes may help reduce gut inflammation, which is linked to AS pathogenesis through the gut-joint axis. The microbiome connection is supported by evidence that intestinal dysbiosis contributes to immune dysregulation in AS, with certain bacterial species potentially triggering inflammatory responses that affect joint tissues in genetically susceptible individuals. Some key points to consider in the management of AS include:

• The use of NSAIDs as first-line treatment for pain and inflammation
• The consideration of biologic medications for patients who do not respond to NSAIDs
• The importance of regular physical therapy to maintain function and mobility
• The potential benefits of microbiome management through dietary changes and probiotics Regular monitoring of disease activity and medication side effects is essential for optimal management, and the treatment approach should be individualized based on the patient's specific needs and response to therapy 1.

From the FDA Drug Label

Enbrel is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis (AS). The treatment approach for Ankylosing Spondylitis includes the use of Etanercept (Enbrel), a TNF-blocker, to reduce signs and symptoms of the disease.

• The recommended dosage for adult patients with Ankylosing Spondylitis is 50 mg weekly, administered by subcutaneous injection.
• There is no direct information in the provided drug labels regarding the management of the microbiome in patients with Ankylosing Spondylitis. 2 2

From the Research

Treatment Approach for Ankylosing Spondylitis

The treatment approach for ankylosing spondylitis involves a combination of pharmacological and non-pharmacological interventions. The primary goal of treatment is to reduce pain, stiffness, and discomfort, and to improve the patient's quality of life.

Pharmacological Interventions

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for ankylosing spondylitis, as they reduce pain and stiffness in most patients 3.
• Disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine may be used in patients with high disease activity, peripheral arthritis, and those with short duration of the disease 4, 5.
• Tumor necrosis factor-alpha (TNF-alpha) blockers such as infliximab, etanercept, and adalimumab are highly efficacious in treating active and severe spondylarthritis, especially in ankylosing spondylitis and psoriatic arthritis 6, 7.
• Analgesics and muscle relaxants may be used in patients with longstanding ankylosing spondylitis refractory to treatment with NSAIDs 4, 5.

Management of the Microbiome

There is no direct evidence on the management of the microbiome in ankylosing spondylitis. However, it is known that the gut microbiome plays a crucial role in the development and progression of the disease. Further research is needed to understand the relationship between the microbiome and ankylosing spondylitis.

Non-Pharmacological Interventions

• Patient education, rest, and a program of physical exercise and physiotherapy are important in reducing stiffness and spinal ankylosis, and improving the patient's quality of life 4.
• Local injections of corticosteroids may be used to manage peripheral arthritis and enthesopathy 4, 5.
• Surgery may be necessary in some cases, and patients with ankylosing spondylitis undergoing surgery should be carefully monitored for silent gastrointestinal bleeding due to the use of NSAIDs and salicylates 5.