Treatment Options for Ankylosing Spondylitis
The treatment of ankylosing spondylitis should follow a stepwise approach, with NSAIDs as first-line therapy, followed by TNF inhibitors or IL-17 inhibitors for patients with persistent disease activity despite NSAID treatment. 1
First-Line Treatment
- NSAIDs are strongly recommended as the initial pharmacological treatment for patients with active ankylosing spondylitis experiencing pain and stiffness 1
- Continuous treatment with NSAIDs is conditionally recommended over on-demand treatment to potentially slow disease progression 1
- No particular NSAID is recommended as the preferred choice, allowing selection based on individual patient factors 1
- Common NSAIDs used include diclofenac, naproxen, and indomethacin, with approximately 78% of patients using them regularly 2
Second-Line Treatment
For patients with active ankylosing spondylitis despite NSAID treatment:
- TNF inhibitors (TNFi) are strongly recommended over no treatment with TNFi 1
- Available TNFi options include infliximab, etanercept, adalimumab, certolizumab, and golimumab 3, 4, 5
- IL-17 inhibitors (secukinumab, ixekizumab) are strongly recommended for patients with active disease despite NSAID treatment 1
- TNFi are conditionally recommended over IL-17 inhibitors as the first biologic choice 1
Special Considerations for Biologic Selection
- For patients with concomitant inflammatory bowel disease or recurrent iritis, TNFi monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) are strongly recommended over etanercept 1, 3
- For patients with primary non-response to the first TNFi, switching to IL-17 inhibitors is conditionally recommended over switching to a different TNFi 3
- For patients with secondary non-response, switching to a different TNFi is conditionally recommended over switching to a non-TNF biologic 3
Conventional DMARDs
- Sulfasalazine, methotrexate, or tofacitinib may be conditionally considered in patients with active AS despite NSAID treatment, particularly in those with prominent peripheral arthritis or when TNFi are not available 1
- There is limited evidence for the efficacy of conventional DMARDs for axial disease 1, 3
Non-Pharmacological Treatment
- Physical therapy is strongly recommended for all patients with ankylosing spondylitis 1
- Regular exercise programs, both supervised and home-based, are conditionally recommended 1, 6
- Patient education and self-management programs are conditionally recommended 1, 6
Surgical Interventions
- Total hip arthroplasty is strongly recommended for patients with advanced hip arthritis 1
- Spinal surgery, including corrective osteotomy and stabilization procedures, may be considered in selected patients with severe kyphosis, though it is conditionally recommended against as an elective procedure 1, 3
Treatment Duration and Monitoring
- Biologic therapy should generally be continued long-term, as the American College of Rheumatology conditionally recommends against discontinuation of biologics in patients with ankylosing spondylitis 1, 3
- Tapering of biologic dose is conditionally not recommended as a standard approach 1, 3
- Regular monitoring of disease activity using validated measures and inflammatory markers (CRP or ESR) is conditionally recommended 1
Treatments to Avoid
- Systemic glucocorticoids are strongly recommended against for the treatment of axial disease in ankylosing spondylitis 1
- Spinal manipulation is strongly recommended against in patients with spinal fusion or advanced spinal osteoporosis 1
Common Pitfalls and Caveats
- NSAIDs carry significant side effect risks, including serious gastrointestinal events and potential cardiovascular effects 1, 2
- Approximately 25% of patients report severe side effects from NSAIDs, most commonly abdominal pain, headache, dizziness, and nausea 2
- Over 20% of patients taking NSAIDs still report insufficient pain control, and more than 40% change their NSAID due to lack of efficacy 2
- Biologics require careful screening for tuberculosis and other infections prior to initiation 4, 5
- Regular monitoring for osteoporosis is conditionally recommended, as patients with ankylosing spondylitis are at increased risk 1