What are the best medications for treating Ankylosing Spondylitis?

Best Medications for Ankylosing Spondylitis

NSAIDs are the first-line medication treatment for ankylosing spondylitis (AS), followed by TNF inhibitors for patients with persistent disease activity despite NSAID therapy. 1

Treatment Algorithm

First-line Treatment

• NSAIDs
  • Strongly recommended as initial therapy for all patients with active AS 1
  • Continuous treatment is conditionally preferred over on-demand treatment 1
  • No particular NSAID is recommended over others 1
  • For patients with increased gastrointestinal risk, use either:
    • Non-selective NSAIDs plus gastroprotective agent (PPI or H2 blocker)
    • COX-2 selective inhibitor 1

Second-line Treatment (if inadequate response to NSAIDs)

• TNF inhibitors (TNFi)
  • Strongly recommended for patients with persistent disease activity despite NSAID therapy 1
  • Options include: etanercept, infliximab, adalimumab, golimumab, certolizumab pegol
  • No particular TNFi is preferred over others 1
  • Exception: For patients with concomitant inflammatory bowel disease, use TNFi monoclonal antibodies (infliximab, adalimumab, golimumab, certolizumab) rather than etanercept 1

Alternative Second-line Options

• IL-17 inhibitors
  • Secukinumab or ixekizumab are strongly recommended for patients with active AS despite NSAID therapy 1
  • However, TNFi are conditionally recommended over IL-17 inhibitors 1

For Peripheral Arthritis

• Sulfasalazine or Methotrexate
  • Conditionally recommended only for patients with prominent peripheral arthritis or when TNFi are not available 1
  • Not effective for axial disease 1

For Treatment Failures

• If primary non-response to first TNFi: Switch to IL-17 inhibitor (secukinumab or ixekizumab) 1
• If secondary non-response to first TNFi: Switch to different TNFi 1

Adjunctive Treatments

• Physical therapy - Strongly recommended for all patients 1
• Local glucocorticoid injections - Conditionally recommended for:
  • Isolated active sacroiliitis
  • Stable axial disease with active enthesitis
  • Stable axial disease with active peripheral arthritis 1

Treatments to Avoid

• Systemic glucocorticoids - Strongly recommended against for axial disease 1
• Adding sulfasalazine/methotrexate to TNFi failure - Conditionally recommended against 1

Important Considerations and Pitfalls

NSAID Use

• Pitfall: Inadequate NSAID trial before escalating therapy
  • Solution: Try at least 2 different NSAIDs at maximum tolerated doses for 2-4 weeks each before considering treatment failure 1
• Pitfall: Ignoring GI risk factors
  • Solution: Assess GI risk and use appropriate gastroprotection in high-risk patients 1

Biologic Therapy

• Pitfall: Delayed initiation of biologics in appropriate patients
  • Solution: Promptly escalate to TNFi or IL-17 inhibitors when disease remains active despite NSAID therapy 1
• Pitfall: Inappropriate switching between biologics
  • Solution: Consider mechanism of failure (primary vs. secondary) when selecting next biologic 1

Disease Monitoring

• Pitfall: Inadequate monitoring of disease activity
  • Solution: Regularly monitor validated AS disease activity measures and inflammatory markers (CRP/ESR) 1

The evidence strongly supports a step-wise approach to AS treatment, starting with NSAIDs and progressing to biologics when necessary, with treatment choices guided by disease manifestations, comorbidities, and previous treatment responses.