What is the recommended treatment for ankylosing spondylitis?

Treatment Recommendations for Ankylosing Spondylitis

NSAIDs are strongly recommended as first-line therapy for active ankylosing spondylitis, with TNF inhibitors strongly recommended for patients who remain active despite NSAID treatment. 1

First-Line Treatment

NSAIDs

• Strong recommendation for NSAIDs as initial therapy for active AS 1, 2
• Continuous NSAID treatment is conditionally recommended over on-demand treatment for persistent disease activity 1
• No particular NSAID is preferred over others 1, 2
• NSAIDs should be used at full therapeutic doses during disease flares 2
• Response to NSAIDs should be assessed within 2-4 weeks 2

Physical Therapy

• Physical therapy is strongly recommended alongside medication 1, 2
• Focus should be on maintaining spinal mobility, improving posture, and strengthening core and neck muscles 2

Second-Line Treatment

For Patients with Active AS Despite NSAIDs

TNF Inhibitors (TNFi)

• Strongly recommended for patients with active disease despite NSAID treatment 1
• Recommended dosing for infliximab: 5 mg/kg IV at weeks 0,2,6, then every 6 weeks 3
• No particular TNFi is recommended as the preferred choice 1
• Exception: TNFi monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) are preferred in patients with concomitant inflammatory bowel disease or recurrent iritis 1

IL-17 Inhibitors

• Secukinumab and ixekizumab are strongly recommended for patients with active AS despite NSAID treatment 1
• However, TNFi are conditionally recommended over IL-17 inhibitors as the first biologic agent 1

Treatment Algorithm for Active AS

1. Start with NSAIDs at full therapeutic doses
2. If inadequate response after 2-4 weeks of NSAID therapy:
   • For predominantly axial disease: Progress to TNFi
   • For peripheral arthritis: Consider sulfasalazine before biologics 1, 2
3. If primary non-response to first TNFi: Switch to IL-17 inhibitor (secukinumab or ixekizumab) 1
4. If secondary non-response to first TNFi: Switch to different TNFi 1

Conventional DMARDs

• Sulfasalazine or methotrexate should be considered only in patients with prominent peripheral arthritis or when TNFi are not available 1
• Conventional DMARDs are not effective for axial disease 2

Important Considerations

Contraindications and Precautions

• Systemic glucocorticoids are strongly recommended against in active AS 1, 2
• Prior to initiating biologics, patients should be evaluated for:
  • Active or latent tuberculosis 3, 4
  • Completion of age-appropriate vaccinations 4

Monitoring

• Regular assessment of disease activity using validated measures
• Monitor CRP or ESR at regular intervals
• Consider bone densitometry for osteoporosis detection, especially in patients with syndesmophytes or spinal fusion 2

Surgical Considerations

• Total hip arthroplasty may be considered in patients with advanced hip arthritis 1
• Corrective spinal osteotomy may be needed for severe debilitating deformity 2

Special Situations

Treatment Failure

• If a patient fails to respond to the first TNFi:
  • With primary non-response: Switch to IL-17 inhibitor 1
  • With secondary non-response: Try a different TNFi 1

Long-term Management

• Continuous NSAID use may potentially reduce radiographic spinal progression, especially in patients with high CRP 5
• Regular follow-up is essential to monitor disease activity and adjust treatment as needed

By following this evidence-based treatment algorithm, clinicians can effectively manage ankylosing spondylitis to improve pain, function, and quality of life while minimizing disease progression.