What are the treatment options for ankylosing spondylitis?

Treatment Options for Ankylosing Spondylitis

The treatment of ankylosing spondylitis requires a combination of pharmacological and non-pharmacological approaches, with NSAIDs as first-line therapy, followed by TNF inhibitors for patients with persistent disease activity despite NSAID treatment. 1

First-Line Pharmacological Treatment

• NSAIDs are strongly recommended as first-line drug treatment for patients with ankylosing spondylitis experiencing pain and stiffness 1
• NSAIDs should be used at the lowest effective dose, with 75% of patients showing a good response within 48 hours 1, 2
• If the first NSAID is not effective after 2-4 weeks, another NSAID may be tried 2, 3
• For patients with increased gastrointestinal risk, either a non-selective NSAID plus a gastroprotective agent or a selective COX-2 inhibitor should be used 1, 3
• Continuous NSAID use may be considered in patients with persistently active disease 4

Second-Line Pharmacological Treatment

• For patients with persistently high disease activity despite NSAID treatment, TNF inhibitors (anti-TNF) are strongly recommended 1, 5
• Available TNF inhibitors for ankylosing spondylitis include adalimumab, etanercept, infliximab, certolizumab, and golimumab 5, 6, 7
• No particular TNF inhibitor is recommended as the preferred choice for axial disease, except in specific circumstances 1
• For patients with concomitant inflammatory bowel disease or recurrent iritis, TNF monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) are preferred over etanercept 1, 5
• Discontinuation of TNF inhibitor therapy is generally not recommended as it results in relapses in 60-74% of patients 5

Disease-Modifying Antirheumatic Drugs (DMARDs)

• There is no evidence supporting the efficacy of conventional DMARDs, including methotrexate and sulfasalazine, for the treatment of axial disease in ankylosing spondylitis 1, 5, 8
• Sulfasalazine may be considered in patients with peripheral arthritis 1, 8
• There is no evidence to support the obligatory use of DMARDs before or concomitant with anti-TNF treatment in patients with axial disease 1, 5

Corticosteroids and Analgesics

• Systemic corticosteroids are strongly not recommended for axial disease in ankylosing spondylitis 1, 2
• Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered 1, 2
• Simple analgesics such as paracetamol and opioids might be considered for pain control in patients in whom NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 2

Non-Pharmacological Treatment

• Physical therapy is strongly recommended for all patients with ankylosing spondylitis 1, 2
• Regular exercise should be recommended to all patients to maintain function 1, 2, 9
• Patient education is an essential component of management 1, 2
• Individual and group physical therapy should be considered 1, 2

Surgical Interventions

• Total hip arthroplasty is strongly recommended for patients with refractory pain or disability and radiographic evidence of structural damage, regardless of age 1, 5
• Spinal surgery, including corrective osteotomy and stabilization procedures, may be valuable in selected patients 1, 5

Monitoring and Disease Assessment

• Regular monitoring of disease activity using validated measures is recommended 1, 5
• Monitoring should include patient history, clinical parameters, laboratory tests (including CRP or ESR), and imaging according to clinical presentation 1, 5
• The frequency of monitoring should be decided on an individual basis depending on symptoms, severity, and drug treatment 1

Important Considerations and Pitfalls

• Early diagnosis and treatment are crucial, as there is typically a 5-7 year delay between first symptoms and diagnosis 1, 2
• NSAIDs carry significant side effect risks, including serious gastrointestinal events (RR 5.36) and potential cardiovascular effects 1, 3
• TNF inhibitors can cause serious infections, including tuberculosis, invasive fungal infections, and other opportunistic infections 6, 7
• Always screen for tuberculosis before initiating TNF inhibitor therapy 6, 7
• For patients with primary non-response to the first TNF inhibitor, switching to a different biologic class may be more effective than switching to another TNF inhibitor 5