What are the treatment options for Ankylosing Spondylitis?

Treatment Options for Ankylosing Spondylitis

NSAIDs are the first-line therapy for ankylosing spondylitis, followed by TNF inhibitors for patients with active disease despite NSAID treatment, with physical therapy strongly recommended throughout all treatment phases. 1

First-Line Treatment

• NSAIDs:
  • First-line pharmacological therapy for active AS
  • Approximately 75% of patients show good response within 48 hours 1
  • On-demand treatment with NSAIDs is conditionally recommended over continuous treatment for stable AS 2
  • Should be administered selectively during periods of high disease activity

Second-Line Treatment (For Active AS Despite NSAIDs)

Biologic Therapy

1. TNF Inhibitors (TNFi):

   • Strongly recommended as first-line biologic therapy 1
   • Options include:
     • Adalimumab (40 mg every other week) 3
     • Etanercept (50 mg weekly) 4
     • Infliximab, golimumab, certolizumab pegol 1
   • Approximately 50% of patients show significant improvement 1
   • Special considerations:
     • For concomitant inflammatory bowel disease: TNFi monoclonal antibodies (adalimumab, infliximab, golimumab, certolizumab) are strongly recommended over etanercept 1
     • For recurrent iritis: Consider TNFi monoclonal antibodies over etanercept 1

2. IL-17 Inhibitors:

   • For patients who fail TNF inhibitors:
     • Secukinumab or ixekizumab conditionally recommended over switching to another TNFi in patients with primary non-response to TNFi 2
     • For secondary non-response to TNFi, conditionally recommended to try a different TNFi before IL-17 inhibitors 2

Conventional Synthetic DMARDs

• Sulfasalazine:

  • Limited efficacy for axial symptoms but may be effective for peripheral joint involvement 1
  • Consider for patients with peripheral arthritis 5
  • Not recommended as primary treatment for axial disease

• Methotrexate:

  • In adults receiving TNFi, conditionally recommended against co-treatment with low-dose methotrexate 2
  • Limited evidence for effectiveness in AS 6

Non-Pharmacological Treatment

• Physical Therapy:

  • Strongly recommended alongside pharmacological treatment 2, 1
  • Helps reduce stiffness and prevent spinal ankylosis 1
  • Land-based physical therapy interventions conditionally recommended over aquatic therapy 2
  • Active physical therapy (supervised exercise) conditionally recommended over passive interventions (massage, ultrasound, heat) 2
  • Unsupervised back exercises conditionally recommended 2

• Self-Management Education:

  • Formal group or individual self-management education conditionally recommended 2

Local Treatments for Specific Manifestations

• For isolated active sacroiliitis: Conditionally recommend locally administered parenteral glucocorticoids 2
• For stable axial disease with active enthesitis: Conditionally recommend locally administered parenteral glucocorticoids (avoid peri-tendon injections of Achilles, patellar, and quadriceps tendons) 2
• For stable axial disease with active peripheral arthritis: Conditionally recommend locally administered parenteral glucocorticoids 2

Important Cautions

• Strongly recommended against:

  • Systemic glucocorticoids 2
  • Switching from originator TNFi to its biosimilar when treatment is working 2
  • Spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis 1

• Conditionally recommended against:

  • Discontinuation of biologic therapy in stable patients 2
  • Tapering of biologic dose as a standard approach 2
  • Addition of sulfasalazine or methotrexate to TNFi in patients who failed first TNFi 2

Monitoring

• Regular assessment of disease activity using validated measures (BASDAI or ASDAS) 1
• Monitor for signs of infection, particularly tuberculosis, before and during TNFi therapy 4, 3
• Fall evaluation and counseling conditionally recommended 2
• Radiographic follow-up not necessary more frequently than every 2 years unless significant clinical changes occur 1

Surgical Options

• Total hip arthroplasty for patients with advanced hip arthritis 1
• Spinal osteotomy generally not recommended for most patients with severe kyphosis due to high risks, but may be considered in highly selected patients with severe kyphosis and lack of horizontal vision 1