What is the treatment protocol for ankylosing spondylitis?

Treatment Protocol for Ankylosing Spondylitis

The optimal treatment protocol for ankylosing spondylitis combines NSAIDs as first-line pharmacotherapy with physical therapy as the foundation, escalating to TNF inhibitor monoclonal antibodies for patients with persistently high disease activity despite conventional treatment. 1

Initial Management: Active Disease

First-Line Pharmacological Treatment

• NSAIDs are strongly recommended as first-line drug treatment for patients with AS presenting with pain and stiffness, with level Ib evidence showing large improvements in spinal pain and function over 6-week periods 1
• Continuous NSAID therapy is preferred over on-demand treatment for patients with persistently active symptomatic disease 1
• For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus a proton pump inhibitor (which reduces serious GI events by 60%) or selective COX-2 inhibitors (which reduce serious GI events by 82% compared to traditional NSAIDs) 1
• Simple analgesics (acetaminophen or opioids) may be added for breakthrough pain when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

First-Line Non-Pharmacological Treatment

• Physical therapy is strongly recommended as a cornerstone treatment and should be initiated concurrently with pharmacological therapy 1
• Supervised group physical therapy demonstrates significantly better patient global assessment compared to home exercise alone, with relative percentage differences of 7.5-18% in spinal mobility measures 1, 2
• Active physical therapy interventions (supervised exercise) are conditionally recommended over passive interventions such as massage, ultrasound, or heat 1
• Land-based physical therapy is conditionally recommended over aquatic therapy 1

Local Corticosteroid Therapy

• Locally administered parenteral glucocorticoids are conditionally recommended for patients with active peripheral arthritis or enthesitis despite NSAID treatment 1
• Systemic corticosteroids for axial disease are not supported by evidence and should not be used 1

Escalation to Biologic Therapy

Indications for TNF Inhibitors

• Anti-TNF treatment is strongly recommended for patients with persistently high disease activity despite conventional NSAID treatment 1
• There is no evidence supporting the obligatory use of DMARDs (such as methotrexate or sulfasalazine) before or concomitant with anti-TNF treatment in patients with axial disease 1
• In patients receiving TNF inhibitor therapy, co-treatment with low-dose methotrexate is conditionally recommended against 1

Selection of TNF Inhibitor

• For patients with inflammatory bowel disease comorbidity, TNF inhibitor monoclonal antibodies (adalimumab, infliximab) are conditionally recommended over etanercept 1
• For patients with recurrent iritis, TNF inhibitor monoclonal antibodies are conditionally recommended over other biologics 1
• Adalimumab dosing for AS: 40 mg subcutaneously every other week 3
• Etanercept dosing for AS: 50 mg subcutaneously weekly 4

Important Caveat on DMARDs

• There is no evidence for the efficacy of conventional DMARDs (including sulfasalazine and methotrexate) for the treatment of axial disease 1
• Sulfasalazine may be considered only in patients with peripheral arthritis 1

Management of Stable Disease

Medication Continuation

• In adults receiving biologic treatment, continuation of the biologic is conditionally recommended over discontinuation 1
• Tapering of biologic dose as a standard approach is conditionally recommended against 1
• In adults receiving TNFi and NSAIDs, continuing TNFi alone is conditionally recommended compared to continuing both treatments 1
• On-demand NSAID treatment is conditionally recommended over continuous NSAIDs in stable disease 1

Ongoing Physical Therapy

• Physical therapy remains strongly recommended even in stable disease 1
• Unsupervised back exercises are conditionally recommended for maintenance 1
• Participation in formal group or individual self-management education is conditionally recommended 1

Disease Monitoring

Assessment Parameters

• Disease monitoring should include patient history (using questionnaires), clinical parameters, laboratory tests (CRP or ESR), and imaging according to clinical presentation and the ASAS core set 1
• Regular-interval use and monitoring of validated AS disease activity measures (such as ASDAS or BASDAI) is conditionally recommended 1
• Regular-interval monitoring of CRP concentrations or ESR is conditionally recommended over usual care without such monitoring 1
• A treat-to-target strategy using ASDAS targets is conditionally recommended against in favor of treatment strategy based on physician assessment 1

Management of Complications and Comorbidities

Osteoporosis Screening

• Screening for osteopenia/osteoporosis with DXA scan is conditionally recommended 1
• In adults with syndesmophytes or spinal fusion, screening for osteoporosis is particularly important 1

Acute Iritis Management

• Treatment by an ophthalmologist is strongly recommended to decrease severity, duration, or complications of acute iritis episodes 1
• For recurrent iritis, prescription of topical glucocorticoids for prompt at-home use is conditionally recommended 1

Fall Prevention

• Fall evaluation and counseling are conditionally recommended, particularly important given the risk of spinal fractures in patients with advanced disease 1

Surgical Interventions

Hip Arthroplasty

• Total hip arthroplasty is strongly recommended in patients with advanced hip arthritis presenting with refractory pain or disability and radiographic evidence of structural damage, independent of age 1

Spinal Surgery

• Corrective osteotomy and stabilization procedures may be of value in selected patients with severe kyphosis, though elective spinal osteotomy is conditionally recommended against in most cases 1
• Spinal manipulation is strongly recommended against in adults with spinal fusion or advanced spinal osteoporosis due to risk of fractures, spinal cord injury, and paraplegia 1

Critical Pitfalls to Avoid

• Do not use systemic corticosteroids for axial disease—there is no evidence supporting their efficacy 1
• Do not require DMARD failure before initiating TNF inhibitors for axial disease—this delays effective treatment 1
• Do not perform spinal manipulation in patients with spinal fusion or advanced osteoporosis—this carries serious risk of catastrophic complications 1
• Do not use etanercept as first choice in patients with inflammatory bowel disease—monoclonal antibody TNF inhibitors are preferred 1
• Screen for latent tuberculosis before initiating TNF inhibitor therapy and monitor for reactivation during treatment 4, 3
• Be aware that TNF inhibitors carry increased risk of serious infections and malignancies, requiring careful patient selection and monitoring 4, 3