Treatment for Ankylosing Spondylitis
The recommended treatment for ankylosing spondylitis involves a combination of NSAIDs as first-line therapy, followed by TNF inhibitors or IL-17 inhibitors for patients with inadequate response to NSAIDs, with TNF inhibitors conditionally recommended as the first biologic choice. 1
Initial Treatment Approach
Non-Pharmacological Interventions
- Patient education is essential, including information about disease course and management expectations 1
- Regular exercise should be incorporated from the beginning to maintain spinal mobility and posture 1
- Calcium and vitamin D supplementation to prevent osteoporosis 1
First-Line Pharmacological Treatment
- NSAIDs are the cornerstone of initial treatment for ankylosing spondylitis 1
- Continuous NSAID treatment is conditionally recommended over on-demand treatment 1
- Monitor patients for gastrointestinal toxicity and other potential side effects of NSAIDs
Treatment for Inadequate Response to NSAIDs
Biologic Therapy Options
TNF inhibitors (infliximab, adalimumab, certolizumab, golimumab)
IL-17 inhibitors (secukinumab, ixekizumab)
- Strongly recommended for patients with active AS despite NSAID treatment 1
- Secukinumab (Cosentyx) is FDA-approved for the treatment of adult patients with active ankylosing spondylitis 2
- Dosing for secukinumab follows specific protocols with loading doses at weeks 0,1,2,3, and 4, followed by maintenance dosing 2
Disease Monitoring
- Use validated disease activity measures (BASDAI or ASDAS) to assess disease activity 1
- Monitor CRP and ESR at regular intervals 1
- Radiographic follow-up generally not necessary more frequently than every 2 years unless significant clinical changes occur 1
Management of Complications and Comorbidities
- Screen for uveitis, inflammatory bowel disease, and psoriasis 1
- Refer to ophthalmologist immediately if acute iritis is present 1
- Evaluate fall risk and provide counseling 1
- Consider DXA scan of both spine and hips to monitor osteoporosis risk 1
Surgical Considerations
- Surgical intervention is indicated only after failure of conservative management for at least 6 weeks 1
- Total hip arthroplasty is strongly recommended for patients with advanced hip arthritis 1
- Spinal osteotomy is generally not recommended for most patients with severe kyphosis due to high risks 1
Important Clinical Considerations
- Early diagnosis and treatment are crucial for preventing structural deformities 1
- Patients with AS have an increased mortality risk compared to the general population, which can be mitigated with adequate treatment 1
- Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis 1
- Prior to initiating biologics like secukinumab, evaluate for active or latent tuberculosis and ensure age-appropriate vaccinations are complete 2