What are the treatment options for ankylosing spondylitis?

Treatment Options for Ankylosing Spondylitis

The optimal management of ankylosing spondylitis requires a combination of non-pharmacological and pharmacological treatments, with NSAIDs as first-line therapy, TNF inhibitors for those with persistent disease activity, and physical therapy as a cornerstone of non-pharmacological management. 1

First-Line Pharmacological Treatment

• NSAIDs are strongly recommended as first-line drug treatment for patients with ankylosing spondylitis experiencing pain and stiffness 1
• Continuous NSAID treatment is preferred for patients with persistently active, symptomatic disease rather than on-demand use 1, 2
• When prescribing NSAIDs, cardiovascular, gastrointestinal, and renal risks should be carefully considered 1, 2
• In patients with increased gastrointestinal risk, a non-selective NSAID plus a gastroprotective agent or a selective COX-2 inhibitor should be used 1, 3

Second-Line Treatment

• For patients with active ankylosing spondylitis despite NSAID treatment, TNF inhibitors (adalimumab, etanercept, infliximab, certolizumab, golimumab) are strongly recommended 1
• No particular TNF inhibitor is preferred except in specific clinical scenarios 1:
  • TNF monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) are preferred over etanercept for patients with concomitant inflammatory bowel disease 1, 2
  • TNF monoclonal antibodies are also preferred for patients with recurrent uveitis 1, 2
• The recommended dosage for TNF inhibitors in ankylosing spondylitis 4, 5:
  • Adalimumab: 40 mg subcutaneously every other week 4
  • Etanercept: 50 mg subcutaneously once weekly 5

Other Pharmacological Options

• Analgesics such as paracetamol and opioids might be considered for residual pain when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
• Conventional synthetic antirheumatic drugs (sulfasalazine, methotrexate) have limited efficacy for axial disease but may be considered for patients with peripheral arthritis 1, 2
• Local corticosteroid injections may be considered for musculoskeletal inflammation sites 1
• Systemic glucocorticoids are not recommended for axial disease 1

Non-Pharmacological Treatment

• Patient education and regular exercise are the cornerstone of non-pharmacological treatment 1
• Physical therapy with supervised exercises (land or water-based, individually or in a group) is strongly recommended and more effective than home exercises alone 1
• Patient associations and self-help groups may provide additional support 1

Management of Extra-articular Manifestations

• Extra-articular manifestations such as psoriasis, uveitis, and inflammatory bowel disease should be managed in collaboration with respective specialists 1
• Rheumatologists should be aware of and monitor for the increased risk of cardiovascular disease and osteoporosis in patients with ankylosing spondylitis 1, 2

Surgical Interventions

• Total hip arthroplasty is strongly recommended for patients with refractory pain or disability and radiographic evidence of structural damage, regardless of age 1
• Spinal surgery, including corrective osteotomy and stabilization procedures, may be valuable in selected patients 1, 2

Treatment Monitoring

• Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation 1, 2
• The frequency of monitoring should be individualized based on symptoms, severity, and drug treatment 1

Common Pitfalls and Caveats

• Delaying TNF inhibitor therapy in patients with persistent high disease activity despite NSAID treatment can lead to unnecessary disease progression and disability 1, 6
• Systemic glucocorticoids should be avoided for axial disease due to lack of evidence for efficacy 1
• Conventional DMARDs (sulfasalazine, methotrexate) should not be used as monotherapy for axial disease due to limited efficacy 1, 2
• Patients on TNF inhibitors should be monitored for serious infections, including tuberculosis, and screened for latent tuberculosis before initiating therapy 4, 5
• Regular assessment of cardiovascular risk factors is important as patients with ankylosing spondylitis have increased cardiovascular risk 1, 2