Treatment Options for Ankylosing Spondylitis
The optimal management of ankylosing spondylitis requires a combination of non-pharmacological and pharmacological treatments, with NSAIDs as first-line drug therapy and anti-TNF agents for refractory cases. 1
Non-Pharmacological Treatment
- Patient education and regular exercise form the cornerstone of non-pharmacological treatment and should be implemented for all patients with AS 1, 2
- Individual and group physical therapy should be considered, with evidence showing that supervised group therapy leads to better patient global assessment outcomes than home exercises alone 1, 2
- Patient associations and self-help groups may provide additional support and resources for patients with AS 1
Pharmacological Treatment Algorithm
First-Line Treatment: NSAIDs
- NSAIDs are the first-line drug treatment for patients with AS experiencing pain and stiffness, with convincing level Ib evidence showing improvement in spinal pain, peripheral joint pain, and function over short periods (6 weeks) 1, 2
- Continuous NSAID treatment is preferred for patients with persistently active, symptomatic disease 3, 4
- For patients with increased gastrointestinal risk, options include:
- Non-selective NSAIDs plus a gastroprotective agent (PPI or misoprostol)
- Selective COX-2 inhibitors 1
Second-Line Options
- Analgesics such as paracetamol and opioids should be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 2
- Corticosteroid injections directed to local sites of musculoskeletal inflammation (such as peripheral joints or entheses) may be beneficial, though systemic corticosteroids are not supported by evidence for axial disease 1, 4
- Sulfasalazine may be considered specifically for patients with peripheral arthritis, but there is no evidence supporting its efficacy for axial disease 1, 5
Biological Therapy: TNF Inhibitors
- Anti-TNF treatment (such as etanercept, infliximab, adalimumab) should be initiated for patients with persistently high disease activity (typically BASDAI >4) despite conventional treatments with at least two NSAIDs for at least 3 months 1, 2, 5
- There is no evidence supporting mandatory use of DMARDs before or with anti-TNF therapy in patients with axial disease 1, 4
- For patients with AS with concomitant inflammatory bowel disease, monoclonal anti-TNF antibodies (infliximab, adalimumab) are preferred over etanercept 3, 6
Surgical Interventions
- Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, regardless of age 1, 4
- Spinal corrective osteotomy and stabilization procedures may be valuable in selected patients with severe disabling deformity 1, 4
Disease Monitoring
- Regular monitoring should include patient history (using validated questionnaires), clinical parameters, laboratory tests (inflammatory markers), and imaging according to clinical presentation 1, 2
- Assessment should evaluate disease activity/inflammation, pain levels, function, disability, structural damage, and comorbidities 3, 4
- Radiographic monitoring may not be needed more frequently than once every 2 years in most cases 1
Common Pitfalls to Avoid
- Overlooking the importance of physical therapy and regular exercise as fundamental components of treatment 2, 6
- Inappropriate use of systemic corticosteroids for axial disease, which lacks supporting evidence 1, 4
- 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) 2, 6
- Failing to consider anti-TNF therapy in patients with persistently active disease despite adequate NSAID trials 2, 4
- Overreliance on DMARDs like methotrexate for axial disease, where evidence of efficacy is lacking 1, 7