What is the initial management for ankylosis spondylitis?

Initial Management of Ankylosing Spondylitis

The initial management of ankylosing spondylitis should begin with NSAIDs as first-line drug treatment for pain and stiffness, combined with patient education and regular exercise programs. 1, 2

Assessment and Diagnosis

• Diagnosis is based on modified New York criteria, which include radiological evidence of sacroiliitis and clinical criteria such as low back pain/stiffness for >3 months that improves with exercise but not rest 1
• Disease monitoring should include patient history, clinical parameters (including BASDAI score), laboratory tests (ESR, CRP), and imaging according to clinical presentation 1
• Assessment should consider disease activity/inflammation, pain levels, function, disability, structural damage, and comorbidities 3

Non-Pharmacological Management

• Patient education and regular exercise are cornerstone treatments and should be initiated immediately upon diagnosis 1, 2
• Individual and group physical therapy should be considered as part of initial management 1
• Home exercise programs improve function in the short term compared to no intervention 3
• Group therapy shows better patient global assessment outcomes than individual therapy alone 1
• Patient associations and self-help groups may provide additional support for newly diagnosed patients 1

Pharmacological Management

First-Line Treatment: NSAIDs

• NSAIDs are recommended as first-line drug treatment for patients with pain and stiffness 1, 4
• There is convincing level Ib evidence that NSAIDs improve spinal pain, peripheral joint pain, and function over short periods (6 weeks) 1
• For patients with increased gastrointestinal risk, consider either non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor 1
• Continuous NSAID treatment is preferred for patients with persistently active, symptomatic disease 2

Second-Line Options

• Analgesics such as paracetamol and opioids might be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be beneficial for peripheral arthritis or enthesitis 1
• Systemic corticosteroids are not recommended for axial disease due to lack of evidence 2

Disease-Modifying Treatment

• Sulfasalazine may be considered in patients with peripheral arthritis but is not effective for axial disease 1, 5
• There is no evidence supporting the use of methotrexate or other conventional DMARDs for axial disease 1
• Anti-TNF treatment (infliximab, etanercept) should be given to patients with persistently high disease activity (BASDAI >4) despite at least two NSAIDs for at least 3 months 1, 6
• The recommended dose of infliximab for ankylosing spondylitis is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks followed by maintenance every 6 weeks 6

Common Pitfalls to Avoid

• Overreliance on imaging findings without correlation to clinical symptoms can lead to unnecessary interventions 3
• Failure to incorporate both pharmacological and non-pharmacological approaches limits treatment effectiveness 3
• Systemic corticosteroids should be avoided for axial disease due to lack of evidence and potential side effects 2
• Not considering anti-TNF therapy in patients with persistently active disease despite adequate NSAID trials 2
• Inadequate trials of NSAIDs before declaring treatment failure (should try at least two different NSAIDs at maximum tolerated dose for at least 3 months each) 1

Treatment Algorithm

1. Start with patient education and prescribed exercise program 1
2. Initiate NSAID therapy at maximum recommended or tolerated dose 1
3. If first NSAID ineffective after 2-4 weeks, switch to a different NSAID 7
4. For peripheral arthritis, consider local corticosteroid injections and/or sulfasalazine 1
5. For persistent high disease activity (BASDAI >4) despite adequate trials of at least two NSAIDs for 3 months, consider anti-TNF therapy 1, 6