Initial Treatment for Ankylosing Spondylitis
Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line drug treatment for ankylosing spondylitis (AS) patients with pain and stiffness, with continuous treatment preferred for patients with persistently active, symptomatic disease. 1, 2
Treatment Algorithm
First-Line Therapy: NSAIDs
- Start with full anti-inflammatory doses of NSAIDs
- Options include:
- Etoricoxib (ranked as most efficacious in network meta-analyses) 3
- Celecoxib
- Naproxen
- Diclofenac
- Meloxicam
- Try at least one NSAID at full therapeutic dose before declaring treatment failure
- Consider cardiovascular, gastrointestinal, and renal risks when prescribing 1
- For patients with high GI risk, use selective COX-2 inhibitors or add gastroprotective agents 2
- Continuous therapy is preferred over on-demand use for patients with persistent symptoms 2
Non-Pharmacological Interventions (Concurrent with NSAIDs)
- Regular exercise is essential to maintain spinal mobility and improve function 2
- Focus on:
- Maintaining spinal mobility
- Improving posture
- Strengthening core muscles
- Gentle stretching
- Supervised exercise programs are preferred over home exercises alone 2
Second-Line Therapy (For NSAID Inadequate Response)
- For patients with peripheral arthritis: Consider sulfasalazine 1, 2
- For patients with persistent active disease despite NSAIDs: Consider TNF inhibitors 2, 4, 5
- Options include: etanercept, adalimumab, infliximab, golimumab, certolizumab
Monitoring and Assessment
- Regular assessment of pain, function, and disease activity
- Monitor for medication side effects, especially GI, renal, and cardiovascular
- Radiographic monitoring generally not needed more frequently than every 2 years 1
Common Pitfalls to Avoid
- Inadequate NSAID dosing: Try at least one NSAID at full therapeutic dose before declaring treatment failure 2
- Using DMARDs like methotrexate for axial disease: These are ineffective for axial symptoms and should be avoided 2
- Using systemic corticosteroids for axial disease: Not supported by evidence and should be avoided 2, 6
- Neglecting the importance of regular exercise: Physical therapy is crucial throughout the disease course 2
- Discontinuing NSAIDs too early: Continuous therapy may be superior in preventing new bone formation 1
Special Considerations
- If a significant change in disease course occurs, consider other causes such as spinal fracture 1
- For elderly patients, start with lower NSAID doses and titrate carefully 2
- For patients with inflammatory bowel disease, selective COX-2 inhibitors may be safer for short-term therapy 1
The management of AS requires balancing effective symptom control with minimizing medication risks. While TNF inhibitors have revolutionized treatment for refractory cases, NSAIDs remain the cornerstone of initial therapy due to their rapid efficacy on inflammatory symptoms 7, 8.