What is the recommended management approach for ankylosing spondylitis (AS)?

Management of Ankylosing Spondylitis

The optimal management of ankylosing spondylitis (AS) requires a combination of non-pharmacological and pharmacological treatment modalities, with NSAIDs as first-line therapy, followed by TNF inhibitors for refractory cases, coordinated by a rheumatologist. 1

Overarching Principles

• AS is a potentially severe disease with diverse manifestations, requiring multidisciplinary treatment coordinated by the rheumatologist 1
• The primary goal is to maximize long-term health-related quality of life through control of symptoms and inflammation, prevention of structural damage, and preservation of function 1
• Treatment should be based on a shared decision between the patient and rheumatologist 1

Treatment Approach

Individualized Treatment Considerations

• Treatment should be tailored according to:
  • Current disease manifestations (axial, peripheral, entheseal, extra-articular) 1
  • Level of current symptoms, clinical findings, and prognostic indicators 1
  • General clinical status (age, gender, comorbidities, concomitant medications, psychosocial factors) 1

Non-Pharmacological Treatment

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

Pharmacological Treatment

First-Line: NSAIDs

• NSAIDs, including COX-2 inhibitors, are recommended as first-line drug treatment for pain and stiffness 1
• Continuous NSAID treatment is preferred for patients with persistently active, symptomatic disease 1
• Consider cardiovascular, gastrointestinal, and renal risks when prescribing NSAIDs 1
• No specific NSAID has proven superior efficacy for AS, though individual patient responses may vary 2, 3

Second-Line: Analgesics

• Analgesics (paracetamol, opioids) may be considered for residual pain when NSAIDs fail, are contraindicated, or poorly tolerated 1

Local Corticosteroids

• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be beneficial 1
• Systemic glucocorticoids are not supported by evidence for axial disease 1

Disease-Modifying Antirheumatic Drugs (DMARDs)

• No evidence supports the efficacy of conventional DMARDs (including methotrexate) for axial disease 1
• Sulfasalazine may be considered specifically for patients with peripheral arthritis 1

Biological Therapy: TNF Inhibitors

• Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments 1
• There is no evidence supporting mandatory use of DMARDs before or with anti-TNF therapy in axial disease 1
• No significant difference in efficacy exists between various TNF inhibitors for axial manifestations 1
• Switching to a second TNF blocker may be beneficial in patients with loss of response 1

Newer Biologics: IL-17 Inhibitors

• Secukinumab is FDA-approved for the treatment of active ankylosing spondylitis in adults 4
• Clinical trials show significant improvements in ASAS20 and ASAS40 responses compared to placebo 4

Surgical Interventions

• Total hip arthroplasty should be considered in patients with refractory pain/disability and radiographic evidence of structural damage 1
• Spinal corrective osteotomy may be considered for severe disabling deformity 1
• Spinal surgeon consultation is recommended for patients with acute vertebral fracture 1

Management of Extra-articular Manifestations

• Extra-articular manifestations (psoriasis, uveitis, inflammatory bowel disease) should be managed in collaboration with respective specialists 1
• Rheumatologists should monitor for increased risk of cardiovascular disease and osteoporosis 1

Common Pitfalls to Avoid

• Delaying diagnosis and appropriate treatment initiation 5
• Inadequate NSAID trials before declaring treatment failure 6
• Overlooking the importance of physical therapy and exercise 1
• Inappropriate use of systemic corticosteroids for axial disease 1
• Failing to consider TNF inhibitors in patients with persistently active disease despite NSAIDs 1, 5

By following this comprehensive approach to AS management, clinicians can help improve outcomes, reduce disease progression, and enhance quality of life for patients with this potentially debilitating condition.