What is the initial treatment for ankylosing spondylitis?

Initial Treatment for Ankylosing Spondylitis

The initial treatment for ankylosing spondylitis should be NSAIDs at maximum tolerated doses, along with physical therapy focused on spinal mobility and posture. 1

First-Line Pharmacological Treatment

NSAIDs

• NSAIDs are the cornerstone of initial treatment for ankylosing spondylitis
• Should be prescribed at maximum tolerated doses for patients with active disease
• Continuous NSAID treatment is preferred over on-demand treatment for persistent symptoms 1
• Consider cardiovascular, gastrointestinal, and renal risks when prescribing 1
• No particular NSAID is universally superior, though historically phenylbutazone was considered the NSAID of choice 2
• Patient-specific factors should guide NSAID selection

NSAID Administration

• Initial trial should be at least 3 months at maximal recommended or tolerated anti-inflammatory dose 3
• If intolerance occurs, try a second NSAID
• Treatment failure is defined as inadequate response to at least two different NSAIDs 3

Non-Pharmacological Interventions

Physical Therapy and Exercise

• Essential component of initial treatment
• Focus on:
  • Spinal mobility exercises
  • Posture improvement
  • Core strengthening
• Should be initiated concurrently with NSAID therapy 1

Patient Education

• Provide information about:
  • Disease course and prognosis
  • Importance of regular exercise
  • Activity modifications to reduce pain while maintaining function

Treatment for Peripheral Joint Involvement

For Peripheral Arthritis

• If peripheral joint symptoms persist despite NSAIDs:
  • Consider local corticosteroid injections for affected joints 3, 1
  • Sulfasalazine may be beneficial specifically for peripheral joint symptoms 3
  • Patients with persistent peripheral arthritis must have a therapeutic trial of sulfasalazine 3

For Enthesitis

• Local corticosteroid injections for symptomatic enthesitis if appropriate local treatment fails 3

Second-Line Treatment

When to Consider Biologics

• If NSAIDs fail after adequate trials (at least two different NSAIDs)
• For predominantly axial symptoms:
  • TNF inhibitors (etanercept, adalimumab, infliximab, golimumab, certolizumab) 1, 4
  • IL-17 inhibitors (secukinumab, ixekizumab) 1
• TNF inhibitors are conditionally recommended over IL-17 inhibitors as first biologic agent 1

Important Considerations Before Starting Biologics

• Screen for tuberculosis and treat latent infection if present 4
• Complete age-appropriate vaccinations 4
• Assess for contraindications including:
  • Active infections
  • Pregnancy or breastfeeding (effective contraception required)
  • History of multiple sclerosis or lupus
  • Malignancy or premalignancy states 3, 4

Disease Monitoring

Assessment Tools

• Use validated disease activity measures:
  • BASDAI (Bath Ankylosing Spondylitis Disease Activity Index)
  • ASDAS (Ankylosing Spondylitis Disease Activity Score)
• Monitor CRP and ESR at regular intervals 1

Imaging

• Initial sacroiliac joint X-rays
• Consider MRI of sacroiliac joints and spine for early detection of inflammation
• Radiographic follow-up generally not necessary more frequently than every 2 years unless significant clinical changes occur 1

Common Pitfalls to Avoid

1. Delayed Treatment: Early diagnosis and treatment are crucial to prevent structural deformities
2. Inadequate NSAID Dosing: Suboptimal dosing may lead to inadequate symptom control
3. Overreliance on DMARDs for Axial Disease: Methotrexate lacks evidence for efficacy in axial disease 1
4. Neglecting Physical Therapy: Medication alone is insufficient; exercise is essential
5. Missing Extra-articular Manifestations: Screen for uveitis, inflammatory bowel disease, and psoriasis

By following this treatment algorithm, most patients with ankylosing spondylitis will experience significant improvement in symptoms and quality of life, with reduced risk of disease progression.