What is the treatment for ankylosing spondylitis (AS)?

Treatment of Ankylosing Spondylitis

NSAIDs are the first-line therapy for ankylosing spondylitis (AS), followed by TNF inhibitors for patients with active disease despite NSAID treatment. 1

First-Line Treatment

• NSAIDs: Strongly recommended as first-line therapy for active AS 1

  • 75% of patients show good response within 48 hours 2
  • Should be used during periods of disease flare-up
  • No specific NSAID is preferred; selection should be based on individual patient response and tolerability
  • Can be administered at higher doses before bedtime for patients with severe nighttime pain and stiffness

• Physical Therapy: Strongly recommended alongside pharmacological treatment 1

  • Helps reduce stiffness and prevent spinal ankylosis
  • Improves physical function and quality of life

Second-Line Treatment

For patients with active AS despite NSAID treatment:

• TNF Inhibitors (TNFi): Strongly recommended 1

  • Options include:
    • Adalimumab
    • Etanercept (Enbrel) 3
    • Infliximab
    • Golimumab
    • Certolizumab pegol
  • No particular TNFi is preferred except in specific circumstances 1
  • Approximately 50% of patients achieve 50% improvement 2

• Special Considerations for TNFi Selection:

  • For patients with concomitant inflammatory bowel disease (IBD): Strongly recommend TNFi monoclonal antibodies (adalimumab, infliximab, golimumab, certolizumab) over etanercept 1
  • For patients with recurrent iritis: Consider TNFi monoclonal antibodies over etanercept 1

Alternative Treatments

• IL-17 Inhibitors (e.g., secukinumab): Alternative for patients who fail TNFi therapy 2

  • TNFi are still conditionally recommended as first-line biologic therapy 2

• Sulfasalazine: Limited efficacy for axial symptoms but may be effective for peripheral joint involvement 2

  • Consider for patients with peripheral arthritis 2

Treatments to Avoid

• Systemic Glucocorticoids: Strongly recommended against for the treatment of active AS 1
  • May be considered as adjunctive therapy for specific manifestations (e.g., local injections for enthesitis)

Surgical Interventions

• Total Hip Arthroplasty: Strongly recommended for patients with advanced hip arthritis 1, 2

  • Provides significant improvements in pain, functioning, and hip range of motion

• Spinal Osteotomy: Generally not recommended for most patients with severe kyphosis due to high risks 2

  • May be considered in highly selected patients with severe kyphosis and lack of horizontal vision

Monitoring and Follow-up

• Regularly assess disease activity using validated tools like Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or Ankylosing Spondylitis Disease Activity Score (ASDAS) 2
• Monitor inflammatory markers (ESR, CRP) to track disease activity, though they may not always be elevated 2
• Radiographic follow-up is not necessary more frequently than every 2 years unless significant clinical changes occur 2

Important Safety Considerations

• For TNFi therapy:

  • Screen for tuberculosis before and during treatment 3
  • Monitor for serious infections that may lead to hospitalization or death 3
  • Be aware of potential risk for malignancies, particularly lymphoma 3
  • Complete all age-appropriate vaccinations before initiating treatment 3

• For patients with comorbidities:

  • Screen for uveitis, inflammatory bowel disease, and psoriasis 2
  • Ensure calcium and vitamin D supplementation to mitigate osteoporosis risk 2
  • Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis 2

The treatment approach for AS has evolved significantly over the years, with TNFi therapy representing a major advancement in management. Early diagnosis and treatment are crucial to prevent structural deformities and improve long-term outcomes.