Treatment Options for Ankylosing Spondylitis
The optimal treatment for ankylosing spondylitis requires a combination of non-pharmacological and pharmacological approaches, with NSAIDs as first-line therapy, followed by TNF inhibitors for patients with persistent disease activity. 1
First-Line Treatment
- NSAIDs are strongly recommended as first-line drug treatment for patients with active AS with pain and stiffness 1
- Continuous treatment with NSAIDs is conditionally recommended over on-demand treatment for patients with persistently active, symptomatic disease 1
- No particular NSAID is recommended as the preferred choice, though selection should consider individual cardiovascular, gastrointestinal, and renal risks 1
- For patients with increased gastrointestinal risk, non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor could be used 1
Non-Pharmacological Treatment
- Physical therapy with supervised exercises is strongly recommended over no treatment with physical therapy 1
- Home exercises are effective, but supervised exercises (land or water-based, individual or group) are preferred as they show greater effectiveness 1
- Patient education is a cornerstone of non-pharmacological treatment 1
- Patient associations and self-help groups may provide additional support 1
Second-Line Treatment
- For patients with active AS despite NSAIDs, TNF inhibitors (TNFi) are strongly recommended over no treatment with TNFi 1
- No particular TNFi is recommended as the preferred choice, except in specific situations 1
- For patients with concomitant inflammatory bowel disease, TNFi monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) are strongly recommended over etanercept 1, 2
- For patients with recurrent uveitis, TNFi monoclonal antibodies are also preferred 1
Newer Biologic Options
- For patients with active AS despite NSAIDs, secukinumab or ixekizumab are strongly recommended over no treatment 1
- However, TNFi are conditionally recommended over secukinumab or ixekizumab as the first biologic option 1
Conventional Synthetic Antirheumatic Drugs (csARDs)
- Sulfasalazine may be considered in patients with peripheral arthritis but has limited efficacy for axial disease 1
- Methotrexate and other csARDs have limited evidence for axial disease but may be considered when TNFi are not available 1
Other Treatment Considerations
- Systemic glucocorticoids are strongly recommended against for the treatment of axial disease 1
- Local corticosteroid injections may be considered for musculoskeletal inflammation sites 1
- Analgesics such as paracetamol and opioids might be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
Surgical Options
- Total hip arthroplasty is strongly recommended for patients with advanced hip arthritis causing refractory pain or disability, regardless of age 1
- Spinal surgery (corrective osteotomy and stabilization procedures) may be valuable in selected patients 1
Treatment Monitoring
- Regular monitoring of disease activity using validated measures and laboratory tests (CRP or ESR) is recommended 1
- Treatment should be tailored according to current disease manifestations (axial, peripheral, entheseal, extra-articular), symptom level, and prognostic indicators 1
Common Pitfalls and Caveats
- Continuous NSAID use may reduce radiographic spinal progression, but must be balanced against potential side effects 3
- Extra-articular manifestations (psoriasis, uveitis, inflammatory bowel disease) should be managed in collaboration with respective specialists 1
- Patients with AS have an increased risk of cardiovascular disease and osteoporosis that should be monitored 1
- TNFi therapy requires screening for tuberculosis and other infections prior to initiation 2, 4