Treatment of Ankylosing Spondylitis
Start all patients with active ankylosing spondylitis on continuous daily NSAIDs at full therapeutic doses combined with physical therapy, and escalate to TNF inhibitor therapy if disease remains active after an adequate NSAID trial. 1, 2
Initial Pharmacologic Management
First-Line NSAID Therapy
Initiate continuous daily NSAIDs at full therapeutic doses rather than on-demand dosing for patients with persistently active disease. 1, 2 This approach provides superior symptom control and may reduce radiographic progression compared to intermittent use.
No specific NSAID is preferred over another—select based on patient comorbidities and tolerability. 1 Common effective options include diclofenac, naproxen, indomethacin, etoricoxib, and celecoxib. 3, 4
Trial 2-3 different NSAIDs at optimal doses before concluding NSAID failure, as individual response varies significantly. 2 Approximately 75% of AS patients show good or very good response to full-dose NSAIDs within 48 hours. 2
Consider COX-2 selective inhibitors (celecoxib, etoricoxib) for patients requiring long-term continuous therapy with gastrointestinal risk factors, as they maintain equivalent efficacy with lower gastric side effects. 1, 2
Account for cardiovascular, gastrointestinal, and renal risks when prescribing NSAIDs. 1 Approximately 25% of patients report severe NSAID-related side effects, most commonly abdominal pain, headache, and nausea. 4
When to Transition from Continuous to On-Demand NSAIDs
- Switch to on-demand NSAID dosing only after achieving stable disease control, as continuous therapy is preferred during active disease phases. 1
Non-Pharmacologic Management
Physical Therapy (Mandatory Component)
Initiate supervised physical therapy simultaneously with NSAID therapy—this is a strong recommendation with moderate-quality evidence. 1, 2 Physical therapy is the cornerstone of non-pharmacological treatment alongside patient education. 1
Prioritize active supervised exercise programs (land-based preferred) over passive modalities such as massage, ultrasound, or heat therapy. 1, 2 Supervised exercises are more effective than home exercises alone. 1
Prescribe unsupervised home back exercises as ongoing self-management between supervised sessions. 1, 2
Recommend participation in formal group or individual self-management education programs. 1
Second-Line Biologic Therapy
TNF Inhibitor Initiation
Strongly recommend TNF inhibitor therapy for patients with persistently high disease activity despite adequate NSAID trial and physical therapy. 1, 2 This is supported by high-quality evidence. 1
No specific TNF inhibitor is preferred as first choice—options include infliximab, etanercept, adalimumab, certolizumab, golimumab, and their biosimilars. 1
For patients with concomitant inflammatory bowel disease or recurrent uveitis, use TNF inhibitor monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) rather than etanercept. 1, 2 This is a conditional recommendation based on low-quality evidence. 1
Do not require concomitant DMARD therapy when initiating TNF inhibitors for axial disease—there is no evidence supporting obligatory DMARD use. 1, 5
Continue NSAIDs and physical therapy when initiating TNF inhibitor therapy. 2
IL-17 Inhibitor Therapy
Strongly recommend secukinumab or ixekizumab for patients with active AS despite NSAIDs, with high-quality evidence supporting efficacy. 1, 6
Conditionally recommend TNF inhibitors over IL-17 inhibitors as first-line biologic choice when no contraindications exist. 1
Managing Biologic Non-Response
For primary non-response to first TNF inhibitor, conditionally recommend switching to secukinumab or ixekizumab over trying a different TNF inhibitor. 1
For secondary non-response to first TNF inhibitor, conditionally recommend switching to a different TNF inhibitor over switching to IL-17 inhibitors. 1, 5
Consider dose escalation before switching biologics in cases of secondary loss of response—for example, infliximab can be increased up to 10 mg/kg per FDA labeling. 5
Conditionally recommend against adding sulfasalazine or methotrexate to failed TNF inhibitor therapy—favor switching to a new biologic instead. 1, 5
Conditionally recommend against discontinuing biologics in patients receiving treatment, as 60-74% experience disease relapse upon discontinuation. 1, 5
Medications to Avoid or Use Selectively
Strongly Contraindicated
Limited or No Role in Axial Disease
Do not use conventional DMARDs (sulfasalazine, methotrexate) for purely axial disease, as there is no evidence of efficacy. 1 These may be considered only for patients with prominent peripheral arthritis. 1, 2
Conditionally recommend against co-treatment with low-dose methotrexate in patients receiving TNF inhibitors. 1
Tofacitinib may be considered for active AS despite NSAIDs, but TNF inhibitors and IL-17 inhibitors are preferred. 1
Selective Local Glucocorticoid Use
- Consider corticosteroid injections directed to local sites of musculoskeletal inflammation for isolated sacroiliitis, enthesitis, or peripheral arthritis despite NSAIDs. 1 Avoid peri-tendon injections of Achilles, patellar, and quadriceps tendons. 1
Analgesics
- Reserve paracetamol and opioid-like drugs for residual pain after recommended treatments have failed, are contraindicated, or poorly tolerated. 1
Management of Extra-Articular Manifestations
Manage psoriasis, uveitis, and inflammatory bowel disease in collaboration with respective specialists. 1
For acute anterior uveitis, strongly recommend immediate treatment by an ophthalmologist. 1
For recurrent uveitis, conditionally recommend TNF inhibitor monoclonal antibodies over other biologics. 1
Be aware of increased cardiovascular disease and osteoporosis risk—conditionally recommend screening for osteopenia/osteoporosis with DXA scan. 1
Special Surgical Considerations
Strongly recommend total hip arthroplasty for patients with advanced hip arthritis. 1
Strongly recommend against spinal manipulation in patients with spinal fusion or advanced spinal osteoporosis due to fracture risk. 1, 2
Conditionally recommend against elective spinal osteotomy in patients with severe kyphosis. 1
Critical Pitfalls to Avoid
Do not interpret normal inflammatory markers (CRP, ESR) as indicating lack of disease activity—clinical symptoms remain the primary determinant of active disease. 5
Do not discontinue biologics based solely on achieving stable disease—maintaining current disease activity prevents progression in this chronic condition. 5
Do not mandate switching from originator TNF inhibitors to biosimilars in stable patients—strongly recommend continuing the originator. 1
Do not use a treat-to-target strategy with specific ASDAS targets over physician assessment-based treatment—this is conditionally recommended against. 1