What is the recommended treatment for ankylosing spondylitis in an outpatient setting?

Treatment for Ankylosing Spondylitis in Outpatient Setting

NSAIDs should be used as first-line pharmacological treatment for ankylosing spondylitis (AS), followed by TNF inhibitors for patients with persistent disease activity, while regular exercise and physical therapy should be implemented throughout the disease course. 1, 2

Treatment Algorithm

First-Line Treatment

1. NSAIDs

   • Start at full anti-inflammatory dose
   • For patients with persistent symptoms, continuous NSAID treatment is preferred over on-demand use 1
   • For patients with increased gastrointestinal risk, use either:
     • Non-selective NSAIDs plus gastroprotective agent
     • Selective COX-2 inhibitor 1, 2
   • No single NSAID has proven superior; selection should be based on individual response and risk factors 2

2. Physical Therapy and Exercise (concurrent with pharmacological treatment)

   • Strongly recommended throughout disease course 1, 2
   • Supervised exercise programs preferred over home exercises alone 1
   • Land-based physical therapy interventions preferred over aquatic therapy 1
   • Focus on:
     • Maintaining spinal mobility
     • Improving posture
     • Strengthening exercises 2, 3

Second-Line Treatment

For patients with persistent active disease despite NSAIDs:

1. TNF Inhibitors (TNFi)

   • Options include etanercept, adalimumab, infliximab, golimumab, certolizumab 1, 4, 5
   • No requirement for prior DMARD use before TNFi for axial disease 2
   • Dosing:
     • Etanercept: 50 mg weekly subcutaneously 4
     • Adalimumab: 40 mg every other week subcutaneously 5

2. IL-17 Inhibitors

   • Secukinumab or ixekizumab recommended if TNFi contraindicated 1
   • For primary non-response to first TNFi, switching to secukinumab/ixekizumab is conditionally recommended 1
   • For secondary non-response to first TNFi, switching to a different TNFi is conditionally recommended 1

For Peripheral Arthritis

• Sulfasalazine may be considered for peripheral joint involvement 2, 6
• Local glucocorticoid injections for active peripheral arthritis or enthesitis 1

Important Considerations

Disease Monitoring

• Regular assessment using validated AS disease activity measures 1
• Monitor CRP or ESR at regular intervals 1
• Consider DXA scan for osteoporosis screening, especially in patients with syndesmophytes or spinal fusion 1

Treatments to Avoid

• Systemic glucocorticoids are strongly recommended against for axial disease 1, 2
• DMARDs (methotrexate, sulfasalazine) are not effective for axial disease 2
• Spinal manipulation should be avoided in patients with spinal fusion or advanced spinal osteoporosis 1

Special Circumstances

• Concomitant inflammatory bowel disease: Use monoclonal antibody TNFi (adalimumab, infliximab) rather than etanercept 1, 2
• Recurrent iritis: TNFi monoclonal antibodies preferred 1
• Advanced hip arthritis: Consider total hip arthroplasty 1

Common Pitfalls to Avoid

1. Using inadequate NSAID dosing before declaring treatment failure
2. Relying on DMARDs like methotrexate for axial disease
3. Using systemic corticosteroids for axial disease
4. Delaying appropriate treatment, which may lead to increased structural damage and disability 2
5. Neglecting physical therapy and exercise, which are essential components of treatment 2, 3

By following this evidence-based approach that combines appropriate pharmacological treatment with consistent physical therapy, most patients with AS can achieve significant improvement in symptoms, function, and quality of life.