What is the initial treatment for lumbar spondylitis?

Initial Treatment for Lumbar Spondylitis

The initial treatment for lumbar spondylitis should include a combination of non-steroidal anti-inflammatory drugs (NSAIDs) at full therapeutic doses, regular exercise, and patient education. 1

Pharmacological Management

First-line Treatment

• NSAIDs: The American College of Rheumatology conditionally recommends continuous NSAID treatment over on-demand treatment for ankylosing spondylitis (AS) patients 1
  • No particular NSAID is preferred over others
  • Should be administered at full therapeutic doses
  • Goal: Reduce inflammation and pain

Second-line Treatment (for patients with inadequate response to NSAIDs)

• Biologic Agents: For patients with persistent active disease despite NSAID treatment:

  • TNF inhibitors (infliximab, adalimumab, certolizumab, golimumab) are strongly recommended 1
  • IL-17 inhibitors (secukinumab, ixekizumab) are also strongly recommended 1
  • TNF inhibitors are conditionally recommended over IL-17 inhibitors as first biologic treatment 1

• For peripheral symptoms:

  • Sulfasalazine, methotrexate, or tofacitinib may be considered when TNF inhibitors are not available 1

Non-Pharmacological Management

• Patient Education: Essential component of initial treatment 2, 1

  • Information about disease course and management expectations
  • Guidance on activity modifications to reduce pain while maintaining function

• Regular Exercise: Should be incorporated from the beginning 2, 1

  • Home exercise programs improve function in the short term
  • Individual and group physical therapy should be considered
  • Focus on maintaining spinal mobility and posture

• Supportive Measures:

  • Patient associations and self-help groups may be useful 2
  • Calcium and vitamin D supplementation to prevent osteoporosis 1

Disease Monitoring

• Monitor disease activity using validated measures (BASDAI or ASDAS) 1
• Laboratory tests: CRP and ESR at regular intervals 1
• Radiographic follow-up generally not necessary more frequently than every 2 years unless significant clinical changes occur 2, 1

When to Consider Advanced Interventions

• Surgical intervention is indicated only after failure of conservative management for at least 6 weeks 2, 1
• Indications for surgical referral include:
  • Progressive neurological deficits
  • Severe, uncontrolled pain
  • Significant functional limitations
  • Failed conservative management 1

Important Considerations and Pitfalls

• Avoid diagnostic delay: Early diagnosis is crucial for initiating effective treatment and preventing structural deformities 1
• Screen for associated conditions: Uveitis, inflammatory bowel disease, and psoriasis 1
• Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis 1
• Evaluate fall risk and provide counseling 1
• Consider comorbidities that may affect treatment choices 1

The combination of pharmacological and non-pharmacological treatments is complementary, and both are valuable in the initial and continuing treatment of patients with ankylosing spondylitis 2. Early and adequately prolonged therapy is essential for optimal outcomes and prevention of disease progression.