Treatment Options for Ankylosing Spondylitis
NSAIDs are recommended as first-line drug treatment for patients with ankylosing spondylitis experiencing pain and stiffness, with TNF inhibitors strongly recommended for patients with persistent high disease activity despite NSAID treatment. 1
First-Line Treatment
- NSAIDs are strongly recommended as the initial pharmacological treatment for patients with ankylosing spondylitis (AS) with pain and stiffness 1
- Continuous NSAID therapy is preferred for patients with persistently active and symptomatic disease 1
- 75% of patients with AS show a good or very good response to NSAIDs within 48 hours, compared to only 15% of patients with mechanical back pain 1
- If the first NSAID is not effective after 2-4 weeks, another NSAID should be tried 2
- For patients with increased gastrointestinal risk, non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor could be used 1
Non-Pharmacological Treatment
- Physical therapy and regular exercise are strongly recommended as fundamental elements of treatment 1, 3
- Patient education and both individual and group physical therapy should be considered 1
- A structured exercise program should be recommended to all patients 2
- Patient associations and self-help groups may be useful 1
Second-Line Treatment
- TNF inhibitors (anti-TNF therapy) are strongly recommended for patients with persistently high disease activity despite NSAID treatment 1, 4
- No particular TNF inhibitor is preferred for axial disease except in specific circumstances 1, 4:
Other Pharmacological Options
- Analgesics such as paracetamol and opioids might be considered for pain control in patients in whom NSAIDs are insufficient, contraindicated, or poorly tolerated 1
- Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered 1
- Systemic corticosteroids are not recommended for axial disease 1
- Disease-modifying antirheumatic drugs (DMARDs) including sulfasalazine and methotrexate have no evidence for efficacy in axial disease but sulfasalazine may be considered in patients with peripheral arthritis 1, 4
Duration and Monitoring of Therapy
- Long-term treatment with TNF inhibitors is generally recommended as discontinuation results in relapses in 60-74% of patients 4
- Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation 1
- Regular monitoring of C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) is conditionally recommended 4
Surgical Options
- Total hip arthroplasty is strongly recommended for patients with refractory pain or disability and radiographic evidence of structural damage, regardless of age 1
- Spinal surgery, including corrective osteotomy and stabilization procedures, may be valuable in selected patients 1
Common Pitfalls and Considerations
- There is typically a 5-7 year delay between first symptoms and diagnosis, which can impact treatment outcomes 1
- NSAIDs carry significant side effect risks, including serious gastrointestinal events (RR 5.36) and potential cardiovascular effects 1, 5
- Over 20% of patients taking NSAIDs report insufficient pain control, and more than 40% change their NSAID due to lack of efficacy 5
- For patients with primary non-response to the first TNF inhibitor, switching to secukinumab or ixekizumab is conditionally recommended over switching to a different TNF inhibitor 4
- For patients with secondary non-response, switching to a different TNF inhibitor is conditionally recommended over switching to a non-TNF biologic 4
- Treatment should be tailored according to disease manifestations (axial, peripheral, entheseal, extra-articular), level of symptoms, and prognostic indicators 1