What are the treatment options for Ankylosing Spondylitis (AS)?

Treatment Options for Ankylosing Spondylitis (AS)

The optimal management of ankylosing spondylitis requires a combination of non-pharmacological and pharmacological treatments, with NSAIDs as first-line therapy and TNF inhibitors for patients with persistent disease activity despite NSAID treatment. 1

First-Line Treatment

NSAIDs

• NSAIDs (including COX-2 inhibitors) are strongly recommended as first-line drug treatment for AS patients with pain and stiffness 1
• Continuous treatment with NSAIDs is preferred for patients with persistently active, symptomatic disease 1
• No specific NSAID has proven superior efficacy for AS, though etoricoxib has been ranked highly in some analyses 2
• Important considerations when prescribing NSAIDs:
  • Monitor for cardiovascular, gastrointestinal, and renal risks 1
  • Patients with increased GI risk should receive either non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor 1

Non-Pharmacological Approaches

• Patient education and regular exercise are the cornerstone of non-pharmacological treatment 1
• Physical therapy with supervised exercises (land or water-based, individual or group) is more effective than home exercises alone 1
• Patient associations and self-help groups may provide additional support 1

Second-Line Treatment

TNF Inhibitors

• Anti-TNF therapy is strongly recommended for patients with persistently high disease activity despite conventional treatments 1
• Key points about TNF inhibitors:
  • No evidence supports mandatory use of DMARDs before or with anti-TNF therapy for axial disease 1
  • No significant difference in efficacy exists between various TNF inhibitors for axial manifestations 1
  • For patients with concomitant inflammatory bowel disease, monoclonal antibody TNF inhibitors (infliximab, adalimumab) are strongly recommended over etanercept 1
  • Switching to a second TNF blocker may be beneficial for patients with loss of response 1

Other Biologics

• Secukinumab (IL-17 inhibitor) is FDA-approved for active AS, showing significant improvements in ASAS20 and ASAS40 responses compared to placebo 3

Additional Treatment Options

DMARDs

• No evidence supports the efficacy of DMARDs (including sulfasalazine and methotrexate) for axial disease 1
• Sulfasalazine may be considered in patients with peripheral arthritis 1

Analgesics

• Paracetamol and opioid-like drugs may be considered for residual pain when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

Glucocorticoids

• Local corticosteroid injections may be used for musculoskeletal inflammation sites 1
• Systemic glucocorticoids are strongly recommended against for axial disease 1

Surgical Options

• Total hip arthroplasty should be considered for patients with refractory pain/disability and radiographic evidence of structural damage, regardless of age 1
• Spinal corrective osteotomy may be considered for severe disabling deformity 1

Management of Extra-articular Manifestations

• Extra-articular manifestations (psoriasis, uveitis, inflammatory bowel disease) should be managed in collaboration with respective specialists 1
• Rheumatologists should monitor for increased risk of cardiovascular disease and osteoporosis 1

Treatment Algorithm

1. Initial approach: NSAIDs + physical therapy/exercise program
2. If inadequate response to first NSAID: Try alternative NSAID at appropriate dosage
3. If persistent high disease activity despite NSAIDs: Initiate TNF inhibitor therapy
4. For peripheral arthritis: Consider sulfasalazine and/or local corticosteroid injections
5. For patients with IBD: Use monoclonal antibody TNF inhibitors rather than etanercept
6. For advanced hip arthritis: Consider total hip arthroplasty

Common Pitfalls and Caveats

• Delaying TNF inhibitor therapy in patients with persistent high disease activity despite NSAID treatment
• Using systemic corticosteroids for axial disease (not supported by evidence)
• Failing to address extra-articular manifestations and comorbidities
• Underutilizing physical therapy and exercise, which are essential components of treatment
• Not considering the specific needs of patients with concomitant conditions (IBD, psoriasis, uveitis) when selecting TNF inhibitors