What is the role of steroids, such as prednisone (corticosteroid), in the management of ankylosing spondylitis?

Role of Steroids in Ankylosing Spondylitis Management

Systemic corticosteroids are NOT recommended for the treatment of axial disease in ankylosing spondylitis, but local corticosteroid injections may be considered for peripheral manifestations such as enthesitis, sacroiliitis, or peripheral arthritis. 1

Systemic Corticosteroids

Axial Disease

• The 2010 ASAS/EULAR recommendations explicitly state that "the use of systemic glucocorticoids for axial disease is not supported by evidence" 1
• The American College of Rheumatology (ACR) strongly recommends against treatment with systemic glucocorticoids for active AS 1
• Evidence for systemic corticosteroid use in axial disease is very limited and of low quality:
  • Only 3 case series and 1 short-term (2-week) randomized placebo-controlled trial of high-dose glucocorticoids exist 1
  • While the randomized trial showed that 5 of 10 outcomes favored prednisolone 50mg daily over placebo, the overall quality of evidence was rated as very low 1

Limited Exceptions for Short-term Use

Despite the general recommendation against systemic corticosteroids, short-term use with rapid tapering might be considered in very limited circumstances:

• Polyarticular flare of peripheral arthritis
• Flares during pregnancy
• Concomitant flares of inflammatory bowel disease 1

Local Corticosteroid Injections

Local corticosteroid injections are conditionally recommended in specific situations:

Sacroiliitis

• For patients with isolated active sacroiliitis despite NSAID treatment, locally administered parenteral glucocorticoids may be considered 1
• Small controlled trials showed improvement in pain for up to 9 months, though studies had serious risk of bias 1

Peripheral Arthritis

• For patients with stable axial disease but active peripheral arthritis despite NSAIDs, local corticosteroid injections may provide symptomatic relief 1
• Short-term oral corticosteroids can be effective for peripheral arthritis but should be discontinued as soon as practicable 1

Enthesitis

• Local corticosteroid injections may be considered for enthesitis that persists despite NSAID treatment 1
• Important caution: Peri-tendon injections of Achilles, patellar, and quadriceps tendons should be avoided due to risk of tendon rupture 1

First-line and Alternative Treatments

Since systemic corticosteroids are not recommended for axial disease, the treatment algorithm should follow:

1. First-line: NSAIDs including COX-2 inhibitors 1, 2

   • Continuous NSAID treatment is conditionally recommended over on-demand treatment 2

2. Second-line (if NSAIDs fail):

   • TNF inhibitors (infliximab, adalimumab, certolizumab, golimumab) 1, 2
   • IL-17 inhibitors (secukinumab, ixekizumab) 2
   • TNF inhibitors are conditionally recommended over IL-17 inhibitors as first biologic 2

3. For peripheral arthritis:

   • Sulfasalazine may be considered 1
   • Local corticosteroid injections for symptomatic relief 1

Perioperative Considerations

For patients with AS undergoing surgery who are on chronic corticosteroids:

• Continue the current daily dose of glucocorticoids rather than administering perioperative supra-physiologic "stress dosing" 1
• This applies to patients receiving ≤16 mg/day prednisone or equivalent 1

Summary

Steroids have a very limited role in AS management. While systemic corticosteroids should be avoided for axial disease, targeted local injections can provide significant symptomatic relief for peripheral manifestations. The mainstay of AS treatment remains NSAIDs and, when needed, biologic agents targeting TNF or IL-17.