What is the initial treatment for moderate spondylitis?

Initial Treatment for Moderate Ankylosing Spondylitis

For moderate ankylosing spondylitis, start with continuous daily NSAIDs at full therapeutic doses combined with physical therapy—this is the cornerstone of initial management before considering biologic therapy. 1

First-Line NSAID Therapy

• Begin with any NSAID at full therapeutic dose, as no specific NSAID has proven superiority over others for pain or stiffness control in ankylosing spondylitis 1
• Use continuous daily dosing rather than on-demand dosing during periods of active disease, as this approach provides better symptom control and may reduce radiographic progression 1
• Trial 2-3 different NSAIDs at optimal doses before concluding NSAID failure, as individual response varies significantly 1
• Consider COX-2 selective NSAIDs for long-term continuous use if gastrointestinal risk factors are present, as they have lower gastric side effects while maintaining equivalent efficacy 1
• 75% of ankylosing spondylitis patients show good or very good response to full-dose NSAIDs within 48 hours, distinguishing inflammatory from mechanical back pain 1

NSAID Selection Considerations

• Indomethacin, celecoxib, naproxen, and diclofenac all demonstrate equivalent efficacy for pain and stiffness reduction 1
• Add proton pump inhibitor gastroprotection for patients with GI risk factors when using traditional NSAIDs 1
• Avoid designating any particular NSAID as preferred—base choice on patient's prior NSAID history, risk factors for adverse effects, and comorbidities 1

Mandatory Concurrent Physical Therapy

• Initiate physical therapy simultaneously with NSAID therapy, as this is a strong recommendation with moderate-quality evidence for functional improvement 1
• Prioritize active supervised exercise programs over passive modalities (massage, ultrasound, heat), as active interventions provide superior outcomes 1
• Recommend land-based exercises over aquatic therapy as the primary approach 1
• Prescribe unsupervised home back exercises as part of ongoing self-management between supervised sessions 1

Critical Management Prohibitions

• Never use systemic glucocorticoids for axial spondylitis—this is a strong recommendation against their use, as they provide no proven benefit 1, 2
• Avoid spinal manipulation in patients with advanced spinal osteoporosis or spinal fusion due to fracture risk 1
• Do not use conventional synthetic DMARDs (sulfasalazine, methotrexate) as initial therapy for purely axial disease—these are conditionally recommended against except for patients with prominent peripheral arthritis 1

When to Escalate to Biologic Therapy

If disease remains active despite adequate NSAID trial and physical therapy, strongly recommend TNF inhibitor therapy as the next step 1, 3

Defining Adequate NSAID Trial

• Trial of 2-3 different NSAIDs at optimal therapeutic doses for sufficient duration (typically 2-4 weeks each at full dose) 1
• Ensure continuous daily dosing rather than intermittent use during the trial period 1
• Confirm adherence to concurrent physical therapy program before declaring treatment failure 1

TNF Inhibitor Selection

• For patients with concomitant inflammatory bowel disease or recurrent uveitis, use monoclonal antibody TNF inhibitors (infliximab, adalimumab, golimumab) rather than etanercept 1, 3
• For patients without these comorbidities, any TNF inhibitor is appropriate as initial biologic choice 1
• Continue NSAIDs and physical therapy when initiating TNF inhibitor therapy 1

Common Pitfalls to Avoid

• Do not use on-demand NSAID dosing for active moderate disease—this is only appropriate for stable disease 1
• Do not add sulfasalazine or methotrexate to NSAIDs for purely axial disease—proceed directly to TNF inhibitor if NSAIDs fail 1
• Do not delay physical therapy while optimizing pharmacologic management—these must occur simultaneously 1
• Do not use inadequate NSAID doses or insufficient trial duration before declaring NSAID failure 1