What is the diagnosis and treatment for Ankylosing Spondylitis (AS)?

From the Guidelines

Ankylosing spondylitis (AS) should be treated with a combination of non-pharmacological and pharmacological approaches, with NSAIDs as the first-line treatment, followed by biologics such as TNF inhibitors or IL-17 inhibitors for patients with inadequate response to NSAIDs. The diagnosis of AS is primarily based on clinical presentation, including symptoms such as back pain and stiffness, and imaging studies like X-rays or MRI to assess sacroiliac joint inflammation and spinal damage 1.

Non-Pharmacological Treatment

Non-pharmacological approaches are essential in the management of AS, including:

• Physical therapy to maintain posture, improve breathing, and enhance spine mobility
• Regular exercise, such as swimming and stretching, to maintain flexibility and posture
• Patient education on proper sleep positions, lifting techniques, and stress management

Pharmacological Treatment

Pharmacological treatment for AS typically involves:

• NSAIDs as the first-line treatment, with options like naproxen (500mg twice daily) or indomethacin (25mg 2-3 times daily) 1
• For patients with inadequate response to NSAIDs, biologics such as TNF inhibitors (e.g., adalimumab 40mg every other week or etanercept 50mg weekly) or IL-17 inhibitors (e.g., secukinumab 150mg monthly after loading doses) are recommended 1
• Treatment with sulfasalazine, methotrexate, or tofacitinib may be considered in patients with prominent peripheral arthritis or when TNF inhibitors are not available 1

Disease Monitoring

Regular monitoring of AS is crucial to prevent irreversible structural damage and maintain quality of life, including:

• Periodic spine imaging to assess disease progression
• Assessment of disease activity using tools like the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
• Regular follow-up appointments with a rheumatologist to adjust treatment plans as needed 1

From the FDA Drug Label

1.4 Ankylosing Spondylitis Enbrel is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis (AS).

2.3 Recommended Dosage in Adult Patients with Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, and Plaque Psoriasis Enbrel is administered by subcutaneous injection (Table 1). Table 1 Recommended Dosage for Adult Patients with RA, AS, PsA and PsO Patient PopulationRecommended Dosage Adult RA, AS, and PsA50 mg weekly

The diagnosis of Ankylosing Spondylitis (AS) is not explicitly stated in the drug label. The treatment for AS is etanercept (Enbrel), administered by subcutaneous injection at a recommended dosage of 50 mg weekly 2.

From the Research

Diagnosis and Treatment of Ankylosing Spondylitis (AS)

• The diagnosis of AS is based on clinical symptoms, such as back pain, stiffness, and discomfort, as well as imaging studies, including X-rays and magnetic resonance imaging (MRI) 3.
• The treatment of AS typically involves a combination of non-pharmacological and pharmacological interventions.

Non-Pharmacological Interventions

• Patient education, rest, and a program of physical exercise and physiotherapy are important components of AS management, helping to reduce stiffness and spinal ankylosis, and improve quality of life 4.

Pharmacological Interventions

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment for AS, providing rapid relief from inflammatory symptoms 5, 4, 3, 6.
• NSAIDs can be divided into two groups: traditional NSAIDs and selective cyclo-oxygenase 2 (COX-2) inhibitors, such as etoricoxib, which may be superior to standard NSAIDs for AS 3.
• Second-line agents, such as sulfasalazine, may be effective in patients with concomitant peripheral arthritis, but are not effective in those with purely axial disease 4, 3.
• Anti-tumor necrosis factor alpha (TNF-alpha) agents, including infliximab, etanercept, and adalimumab, have been shown to be effective in treating AS, with response rates of about 60% 3, 7.
• These agents can be used as monotherapy, and concomitant methotrexate appears to offer no advantages, although insufficient doses have been used to date 3.

Specific Treatment Considerations

• Enthesopathy may be treated with local injection of corticosteroids, while sacroiliac joint pain may be managed by corticosteroid injection performed under fluoroscopic control or guided by computed tomography 4.
• AS complicated by psoriasis or inflammatory bowel disease is treated as primary AS, while AS occurring in juveniles is best treated with aspirin and an NSAID, with careful observation for the development of Reye's syndrome and gastric irritation 5.
• During pregnancy and lactation, ibuprofen may be the preferred drug in AS 5.