What is the initial treatment for ankylosing spondylitis?

Initial Treatment for Ankylosing Spondylitis

Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line drug treatment for patients with ankylosing spondylitis with pain and stiffness. 1

Pharmacological Treatment Algorithm

First-Line Treatment: NSAIDs

• Start with full therapeutic doses of NSAIDs
• Continuous treatment is preferred for patients with persistently active, symptomatic disease 1
• Consider cardiovascular, gastrointestinal, and renal risks when selecting specific NSAIDs 1
• For patients with increased gastrointestinal risk, use either:
  • Non-selective NSAIDs plus a gastroprotective agent
  • A selective COX-2 inhibitor 2
• Try at least one NSAID at full therapeutic dose before declaring treatment failure 1

Second-Line Treatment (for NSAID-refractory cases)

• TNF inhibitors (for patients with persistent active disease despite NSAIDs) 1:

  • Etanercept 50 mg weekly 3
  • Infliximab 5 mg/kg at weeks 0,2,6, and then every 6-8 weeks 4
  • Other options: adalimumab, golimumab, certolizumab

• IL-17 inhibitors (if TNF inhibitors are contraindicated or ineffective) 1:

  • Secukinumab
  • Ixekizumab

For Peripheral Joint Involvement

• Sulfasalazine may be considered for peripheral arthritis 1
• Note: Sulfasalazine is not effective for axial disease 1

Non-Pharmacological Treatment

Non-pharmacological treatment should be implemented alongside medication and includes:

1. Regular Exercise - Cornerstone of non-pharmacological treatment 1

   • Supervised exercise programs are preferred over home exercises alone
   • Focus on maintaining spinal mobility, improving posture, and strengthening core muscles

2. Physical Therapy - Should be considered throughout disease course 2, 1

   • Land-based physical therapy interventions preferred over aquatic therapy

3. Patient Education - About disease course and management expectations 2, 1

Monitoring Disease Activity

• Regular assessment using validated AS disease activity measures 1
• Monitor CRP or ESR at regular intervals 1
• Assess pain, function, and medication side effects (especially GI, renal, and cardiovascular) 1

Common Pitfalls to Avoid

1. Inadequate NSAID dosing before declaring treatment failure 1
2. Using systemic corticosteroids for axial disease - Not supported by evidence 1
3. Relying on DMARDs like methotrexate for axial disease - Ineffective 1
4. Neglecting the importance of regular exercise and physical therapy - Can worsen outcomes 1

Evidence Quality and Considerations

The recommendations for NSAIDs as first-line therapy have strong evidence support. There is convincing evidence (level Ib) that NSAIDs improve spinal pain, peripheral joint pain, and function over a short time period 2. Recent evidence suggests that continuous NSAID treatment may retard radiographic disease progression compared to on-demand use 2, 5.

For TNF inhibitors, clinical trials show significant improvement in disease activity. For example, infliximab demonstrated 60% of patients achieving ASAS 20 response at 24 weeks compared to 18% with placebo 4, while etanercept has also shown efficacy in reducing signs and symptoms in patients with active ankylosing spondylitis 3.