From the Guidelines
Ankylosing spondylitis should be managed with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, and biologics such as tumor necrosis factor inhibitors (TNFi) should be used when activity persists despite NSAID treatment, as recommended by the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network in 2016 1.
Treatment Approach
The treatment approach for ankylosing spondylitis typically involves a combination of pharmacological and non-pharmacological interventions.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (500mg twice daily) or indomethacin (25mg 2-3 times daily) are recommended as first-line therapy to reduce inflammation and pain 1.
- For patients who do not respond adequately to NSAIDs, biologics such as TNF inhibitors (e.g., adalimumab 40mg every other week or etanercept 50mg weekly) are recommended 1.
- Regular physical therapy and exercise are crucial components of management, focusing on posture, breathing exercises, and maintaining spinal flexibility.
- Disease monitoring should include periodic assessment of disease activity, spinal mobility, and radiographic progression.
Disease Management
Ankylosing spondylitis is a chronic inflammatory disease that requires long-term management to prevent irreversible structural damage.
- Early diagnosis and treatment are essential to improve long-term outcomes, as the disease typically affects young adults, particularly men, and has a genetic component linked to HLA-B27.
- Patients should be aware that maintaining good posture, avoiding smoking, and adhering to treatment regimens can significantly improve long-term outcomes.
- The use of systemic glucocorticoids is not recommended, and hip arthroplasty may be considered for patients with advanced hip arthritis 1.
From the Research
Overview of Ankylosing Spondylitis Treatment
- Ankylosing spondylitis (AS) is a chronic inflammatory disease characterized by lower back pain, enthesitis, and asymmetrical peripheral arthritis 2.
- The main objective of initiating therapy is to reduce pain, stiffness, and discomfort 3.
Drug Treatment Options
- There are three groups of drugs available for the management of AS:
- Drugs that influence the disease process itself, such as sulfasalazine 3.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), which suppress inflammation without influencing the disease process 3, 4, 2.
- Analgesics and muscle relaxants, which should be used rather frequently in patients with longstanding AS refractory to treatment with NSAIDs 3.
Efficacy of NSAIDs
- NSAIDs are recommended as a first-line drug treatment for AS 2.
- All NSAIDs were significantly more effective in reducing pain severity than placebo, with mean differences ranging from -17.49 to -25.99 2.
- Etoricoxib was ranked as the most efficacious treatment for patients with AS 2.
Efficacy of Biological Agents
- TNF-alpha inhibitors, such as adalimumab, etanercept, golimumab, and infliximab, have been shown to improve clinical symptoms in the treatment of AS 5.
- There was high-quality evidence that patients on an anti-TNF agent were three to four times more likely to achieve an ASAS40 response compared to placebo 5.
- The number needed to treat to achieve an ASAS 40 response ranged from 3 to 5 5.
Safety of Treatment Options
- NSAIDs may cause gastrointestinal and renal side effects, and high doses may be prescribed before bedtime in patients suffering from severe pain and stiffness during the night 3.
- The toxicity profile of anti-TNF agents appears acceptable, but regulatory agencies have published warnings about rare adverse events, including tuberculosis, malignancies, and lymphoma 5.