Is Ankylosing Spondylitis Treatable?
Yes, ankylosing spondylitis is definitively treatable with a combination of non-pharmacological and pharmacological interventions that can control symptoms, reduce inflammation, prevent structural damage, and maximize long-term quality of life. 1
Treatment Goals
The primary treatment objectives are to maximize long-term health-related quality of life through control of symptoms and inflammation, prevention of progressive structural damage, preservation/normalization of function, and maintenance of social participation. 1
First-Line Treatment Approach
Non-Pharmacological Management (Essential Foundation)
Patient education and regular exercise are the cornerstone of non-pharmacological treatment. 1, 2 This is not optional—it forms the foundation upon which all other treatments build.
Supervised physical therapy (land or water-based, individual or group) is more effective than home exercises alone and should be preferred when available. 1 Group therapy demonstrates better patient global assessment outcomes than individual therapy. 2
Home exercise programs do improve function in the short term compared to no intervention, but supervised programs yield superior results. 2
Pharmacological First-Line Treatment
NSAIDs (including COX-2 inhibitors) are recommended as first-line drug treatment for AS patients with pain and stiffness. 1, 2 There is convincing level Ib evidence that NSAIDs improve 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 rather than intermittent use. 1
For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor. 2
Cardiovascular, gastrointestinal, and renal risks must be assessed before prescribing NSAIDs. 1
Second-Line Treatment
When to Escalate
Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments (NSAIDs and exercise). 1, 3
The FDA-approved etanercept (Enbrel) is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis, administered as 50 mg weekly by subcutaneous injection. 3
There is no evidence supporting the obligatory use of disease-modifying antirheumatic drugs (DMARDs) before or concomitant with anti-TNF therapy in patients with axial disease. 1
Important Distinction for Peripheral Disease
- Sulfasalazine may be considered in patients with peripheral arthritis, but there is no evidence for efficacy of DMARDs (including sulfasalazine and methotrexate) for treatment of axial disease. 1
Additional Treatment Options
Analgesics and Corticosteroids
Analgesics such as paracetamol and opioid-like drugs might be considered for residual pain after previously recommended treatments have failed, are contraindicated, or poorly tolerated. 1
Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered. 1, 2
Systemic glucocorticoids for axial disease should be avoided—there is no evidence supporting their use. 1 This is a critical pitfall to avoid.
Surgical Interventions
Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage. 2
Spinal surgery, including corrective osteotomy and stabilization procedures, may be valuable in selected patients. 2
Monitoring Strategy
Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation. 2
Assessment should evaluate disease activity/inflammation, pain levels, function, disability, structural damage, and comorbidities. 2
Radiographic monitoring is generally not needed more often than once every 2 years, though exceptions exist for rapidly progressing cases. 2
Multidisciplinary Coordination
AS is a potentially severe disease with diverse manifestations, usually requiring multidisciplinary treatment coordinated by the rheumatologist. 1
Extra-articular manifestations (psoriasis, uveitis, inflammatory bowel disease) should be managed in collaboration with respective specialists. 1
Rheumatologists should be aware of the increased risk of cardiovascular disease and osteoporosis in AS patients. 1
Critical Pitfalls to Avoid
Never rely on systemic corticosteroids for axial disease—this lacks evidence and exposes patients to unnecessary side effects. 1
Do not delay anti-TNF therapy in patients with persistently high disease activity despite NSAIDs and exercise—early intervention prevents irreversible structural damage. 1
Avoid overreliance on imaging findings without correlation to clinical symptoms, which can lead to unnecessary interventions. 2
Do not use DMARDs as a prerequisite for anti-TNF therapy in axial disease—this delays effective treatment without benefit. 1