Treatment of Spondylosis
For active ankylosing spondylitis, start with NSAIDs as first-line therapy, escalate to TNF inhibitors if NSAIDs fail, and maintain non-pharmacological interventions including physical therapy and regular exercise throughout the disease course. 1
First-Line Pharmacological Treatment
NSAIDs are strongly recommended as the initial drug treatment for patients with pain and stiffness. 1 The evidence supporting this approach is robust:
- NSAIDs demonstrate level Ib evidence for improving spinal pain, peripheral joint pain, and function over 6-week periods 1
- No particular NSAID is superior to others, so selection should be based on individual tolerability and gastrointestinal risk profile 1
- Continuous NSAID therapy is conditionally recommended over on-demand use, as continuous treatment may retard radiographic disease progression 1
Managing Gastrointestinal Risk
For patients with increased GI risk, use either non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 1
Non-Pharmacological Treatment (Essential Throughout Disease Course)
Physical therapy is strongly recommended and should be initiated early and maintained continuously. 1, 2
- Patient education and regular exercise are fundamental components of management 1, 2
- Home exercise programs improve function in the short term compared to no intervention 1
- Group physical therapy shows better patient global assessment outcomes than home exercise alone 1
- Avoid spinal manipulation in patients with spinal fusion or advanced spinal osteoporosis 1
Second-Line Pharmacological Treatment
When NSAIDs Fail
If disease remains active despite adequate NSAID therapy, TNF inhibitors are strongly recommended over no biologic treatment. 1 This represents high-quality evidence:
- TNF inhibitors (infliximab, etanercept, adalimumab, certolizumab, golimumab, and biosimilars) show rapid and strong effects on disease activity, function, spinal mobility, and inflammation 1, 2
- No particular TNF inhibitor is preferred over others 1
- TNF inhibitors are conditionally recommended over IL-17 inhibitors (secukinumab/ixekizumab) as the preferred biologic 1
Alternative Biologics
If NSAIDs fail and TNF inhibitors are not suitable:
- Secukinumab or ixekizumab are strongly recommended over no biologic treatment (high-quality evidence) 1
- These IL-17 inhibitors are conditionally recommended over tofacitinib 1
Role of Conventional DMARDs
Sulfasalazine or methotrexate should be considered only in patients with prominent peripheral arthritis or when TNF inhibitors are unavailable (conditional recommendation, very low to moderate evidence) 1
Third-Line Treatment
After First TNF Inhibitor Failure
If the first TNF inhibitor fails, secukinumab or ixekizumab are conditionally recommended over sulfasalazine, methotrexate, or tofacitinib. 1
After Second TNF Inhibitor Failure
An alternative TNF inhibitor may be considered 1
Management of Stable Disease
For patients achieving stable disease on biologics:
- Continue the biologic alone; conditionally recommend stopping NSAIDs 1
- Conditionally recommend against discontinuing the biologic 1
- Conditionally recommend against tapering the biologic dose as standard approach 1
- Do not co-treat with low-dose methotrexate (conditional recommendation) 1
Critical Pitfalls to Avoid
Medication-Related
- Never mandate switching from originator TNF inhibitor to biosimilar (strong recommendation against) 1
- Do not use conventional DMARDs (sulfasalazine, methotrexate) for axial disease without peripheral involvement 1
- Avoid spinal manipulation in patients with advanced disease 1
Comorbidity Management
- For recurrent iritis, TNF inhibitor monoclonal antibodies are conditionally recommended over other biologics 1
- For inflammatory bowel disease, TNF inhibitor monoclonal antibodies are conditionally recommended over other biologics 1
Surgical Considerations
Total hip arthroplasty is strongly recommended for patients with advanced hip arthritis causing refractory pain or disability (strong recommendation despite very low evidence) 1, 3
Spinal osteotomy is conditionally recommended against for severe kyphosis except in highly selected cases 1