Best Pain Medications for Ankylosing Spondylitis

NSAIDs are the recommended first-line drug treatment for pain and stiffness in ankylosing spondylitis patients. 1

First-Line Treatment: NSAIDs

NSAIDs provide convincing evidence (level Ib) of improvement in spinal pain, peripheral joint pain, and function over short time periods (6 weeks) 1
No specific NSAID has been shown to be clearly superior to others for AS pain management 1, 2
In clinical studies with AS patients, naproxen has demonstrated effectiveness in decreasing night pain, morning stiffness, and pain at rest 3
Etoricoxib ranks highest in efficacy for AS pain relief according to network meta-analysis, though all NSAIDs showed significant pain reduction compared to placebo 2
Continuous NSAID treatment may be preferred over intermittent "on demand" use, as one study suggests continuous treatment might retard radiographic disease progression 1

For patients with increased gastrointestinal risk, options include:
- Non-selective NSAIDs plus a gastroprotective agent 1
- Selective COX-2 inhibitors (coxibs) 1
Coxibs have lower risk of serious GI events than traditional NSAIDs but require consideration of cardiovascular risk factors 1
Diclofenac and naproxen carry higher risk of GI events than placebo 2
The choice between NSAIDs or coxibs should be based on the patient's GI risk profile and concomitant cardiovascular risk factors 1

For patients in whom NSAIDs are insufficient, contraindicated, or poorly tolerated, analgesics such as paracetamol (acetaminophen) and opioids might be considered for pain control 1
Simple analgesics have not been prospectively studied specifically for AS pain management 1
Paracetamol has shown GI toxicity not significantly higher than placebo in level 1a studies in other musculoskeletal diseases 1

Corticosteroid injections directed to local sites of musculoskeletal inflammation may be considered for targeted pain relief 1
Intra- or periarticular corticosteroid injections have shown effectiveness for sacroiliitis pain in small RCTs (level Ib evidence) 1
Local corticosteroid injections may be helpful for enthesitis (inflammation at tendon/ligament insertion sites) in selected cases, though potential risks including tendon rupture must be considered 1

For patients with persistently high disease activity despite NSAID treatment, anti-TNF therapy should be considered 4
TNF inhibitors such as adalimumab have demonstrated significant improvement in AS symptoms, with ASAS 20/50/70 responses achieved by 58%, 38%, and 23% of patients respectively at 12 weeks 5
Anti-TNF treatment can lead to improvement in quality of life measures and physical function in AS patients 5

NSAIDs carry significant side effect risks, including serious gastrointestinal events (RR 5.36) and potential cardiovascular effects 1
In population surveys, approximately 25% of AS patients report severe side effects from NSAID treatment, most commonly abdominal pain, headache, dizziness, and nausea 6
Despite NSAID therapy, over 20% of AS patients still report insufficient pain control, and more than 40% change their NSAID due to lack of efficacy 6
DMARDs including sulfasalazine and methotrexate have no evidence supporting their efficacy for axial disease pain but may be considered for peripheral arthritis 1, 4

Start with NSAIDs as first-line therapy for pain and stiffness 1
If initial NSAID is ineffective or poorly tolerated, try an alternative NSAID 6
For patients with GI risk factors, use either a non-selective NSAID with gastroprotection or a COX-2 inhibitor 1
For localized pain, consider targeted corticosteroid injections 1
For patients with inadequate response to NSAIDs, add simple analgesics 1
For persistent high disease activity despite optimal NSAID therapy, progress to anti-TNF therapy 4