What is the initial treatment for ankylosing spondylitis?

Initial Treatment for Ankylosing Spondylitis

NSAIDs are the first-line therapy for ankylosing spondylitis (AS), with 75% of patients showing a good response within 48 hours. 1

Pharmacological Treatment Algorithm

First-Line Therapy

• NSAIDs
  • Should be used as initial treatment for all patients with active AS
  • No specific NSAID is preferred; selection should be based on patient factors
  • Most patients (75%) show good response within 48 hours 1
  • Can be administered during periods of disease flare-up to reduce pain and stiffness
  • Consider higher doses before bedtime for patients with severe nighttime pain and stiffness

Second-Line Therapy (if inadequate response to NSAIDs)

• TNF Inhibitors (TNFi)
  • Options include adalimumab, infliximab, golimumab, and certolizumab pegol
  • Approximately 50% of patients show significant improvement with TNFi therapy 1
  • Special considerations:
    • For patients with concomitant inflammatory bowel disease: Use TNFi monoclonal antibodies (adalimumab, infliximab, golimumab, certolizumab) rather than etanercept 1
    • For patients with recurrent iritis: Consider TNFi monoclonal antibodies over etanercept 1

Third-Line Therapy (if inadequate response to TNFi)

• IL-17 Inhibitors
  • Secukinumab is effective for active AS 2
  • Clinical trials show significant improvements in ASAS20 and ASAS40 responses compared to placebo 2

For Peripheral Joint Involvement

• Sulfasalazine
  • Limited efficacy for axial symptoms but may be effective for peripheral joint involvement 1
  • Consider in patients with high disease activity, peripheral arthritis, and short disease duration

Non-Pharmacological Treatment

• Physical Therapy

  • Should be prescribed alongside pharmacological treatment
  • Helps reduce stiffness and prevent spinal ankylosis
  • Improves physical function and quality of life 1

• Regular Disease Activity Monitoring

  • Use validated tools like BASDAI or ASDAS to assess treatment response 1
  • Monitor inflammatory markers (ESR, CRP) to track disease activity, though they may not always be elevated 1

Important Considerations and Pitfalls

1. NSAID Safety

   • Monitor for gastrointestinal side effects, particularly with diclofenac and naproxen 3
   • Consider gastroprotective agents in high-risk patients

2. Radiographic Follow-up

   • Not necessary more frequently than every 2 years unless significant clinical changes occur 1

3. Bone Health

   • Ensure calcium and vitamin D supplementation
   • Consider DXA scan of both spine and hips to monitor osteoporosis risk 1

4. Contraindications

   • Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis 1
   • Evaluate fall risk and provide counseling 1

5. Treatment Failure

   • Before categorizing a patient as "refractory to NSAID therapy," ensure adequate trials of different NSAIDs at optimal dosages

By following this treatment algorithm, most patients with ankylosing spondylitis can achieve significant improvement in symptoms and quality of life. Early intervention is crucial to prevent structural deformities and reduce mortality risk associated with the disease.