What is the treatment for ankylosing spondylitis (AS)?

Treatment of Ankylosing Spondylitis

NSAIDs are the first-line pharmacological treatment for ankylosing spondylitis (AS), followed by TNF inhibitors for patients with persistent disease activity despite NSAID therapy. 1, 2

First-Line Treatment

NSAIDs

• Start with full therapeutic doses of NSAIDs for maximum anti-inflammatory effect
• 75% of AS patients show good response to NSAIDs within 48 hours 2
• Continuous NSAID treatment is preferred for patients with persistently active, symptomatic disease 2
• No single NSAID has proven superior; selection should be based on individual response and risk factors 2
• For patients with increased gastrointestinal risk, use either:
  • COX-2 selective NSAIDs
  • Non-selective NSAIDs plus gastroprotective agent 2

Physical Therapy and Exercise

• Strongly recommended alongside pharmacological treatment 1, 2
• Supervised exercise programs show better outcomes than home exercise alone 2
• Focus on maintaining spinal mobility and improving posture

Second-Line Treatment

TNF Inhibitors (TNFi)

• Strongly recommended for patients with active AS despite NSAID treatment 1
• No particular TNFi is preferred except in specific cases:
  • For patients with concomitant inflammatory bowel disease or recurrent iritis, TNFi monoclonal antibodies (infliximab, adalimumab) are strongly recommended over etanercept 1, 2
• Switching to a second TNF blocker may be beneficial for patients with loss of response 2

IL-17 Inhibitors

• Secukinumab is FDA-approved for active AS 3
• Demonstrated significant improvements in ASAS40 responses compared to placebo 3

Treatments for Peripheral Arthritis

DMARDs

• Sulfasalazine may be considered for patients with peripheral arthritis 2
• Not effective for axial disease 1, 2
• No evidence supports mandatory use of DMARDs before or with TNFi therapy for axial disease 2

Treatments to Avoid

Systemic Glucocorticoids

• Strongly recommended against for axial disease 1, 2
• Local corticosteroid injections may be used for specific sites of musculoskeletal inflammation 2

Surgical Options

Total Hip Arthroplasty

• Strongly recommended for patients with advanced hip arthritis 1
• Should be considered regardless of age for patients with refractory pain/disability and radiographic evidence of structural damage 2

Spinal Corrective Osteotomy

• May be considered for severe disabling deformity 2

Monitoring and Prevention

• Monitor for gastrointestinal, cardiovascular, and renal side effects of NSAIDs 2
• Assess for increased risk of cardiovascular disease and osteoporosis 2
• Manage extra-articular manifestations in collaboration with respective specialists 2

Common Pitfalls to Avoid

• Using inadequate NSAID dosing before declaring treatment failure
• Failing to try at least one NSAID at full therapeutic dose before moving to second-line treatments
• Using systemic corticosteroids for axial disease
• Relying on DMARDs like methotrexate for axial disease, which is ineffective 2

The treatment approach for AS has evolved significantly, with strong evidence supporting NSAIDs and TNFi as effective treatments for reducing symptoms, maintaining function, and improving quality of life in patients with AS.