Treatment of Ankylosing Spondylitis
NSAIDs are the first-line pharmacological treatment for ankylosing spondylitis, and for patients with persistently active disease despite NSAIDs, TNF inhibitors should be initiated. 1
First-Line Treatment: NSAIDs
NSAIDs (including COX-2 inhibitors) are strongly recommended as first-line drug therapy for AS patients experiencing pain and stiffness. 1, 2
For patients with persistently active, symptomatic disease, continuous NSAID treatment is preferred over on-demand use, as evidence suggests continuous therapy may retard radiographic disease progression. 1, 2
No specific NSAID has been proven superior to others for AS treatment, so selection should be based on individual patient factors including gastrointestinal and cardiovascular risk profiles. 1, 2
For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors. 1, 2
Cardiovascular, gastrointestinal, and renal risks must be assessed and monitored when prescribing NSAIDs. 1
Non-Pharmacological Treatment (Essential Component)
Patient education and regular exercise are the cornerstone of non-pharmacological treatment and should be implemented for all AS patients. 1
Physical therapy with supervised exercises (land or water-based, individual or group) is more effective than home exercises alone and should be preferred. 1
Second-Line Treatment: TNF Inhibitors
For patients with persistently high disease activity despite conventional NSAID treatment, anti-TNF therapy should be initiated according to ASAS recommendations. 1
There is no evidence requiring obligatory use of DMARDs before or concomitant with anti-TNF therapy in patients with axial disease. 1, 3
All TNF inhibitors (infliximab, etanercept, adalimumab, certolizumab, golimumab) show similar efficacy for axial and articular/entheseal manifestations, with one critical exception: 1
For AS patients with concomitant inflammatory bowel disease, TNF inhibitor monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) are strongly recommended over etanercept due to differences in gastrointestinal efficacy. 1, 4, 5
Switching to a second TNF blocker may be beneficial, especially in patients with loss of response to the first agent. 1
Third-Line Treatment: IL-17 Inhibitors
For patients with active AS despite TNF inhibitor failure, secukinumab or ixekizumab (IL-17 inhibitors) are recommended over tofacitinib. 1
Against switching to a biosimilar of the first TNF inhibitor in non-responders; instead, switch to a different TNF inhibitor or IL-17 inhibitor. 1
Role of DMARDs
There is no evidence supporting the efficacy of DMARDs (including sulfasalazine and methotrexate) for treating axial disease in AS. 1, 2
Sulfasalazine may be considered only for patients with peripheral arthritis. 1
Glucocorticoids
Systemic glucocorticoids for axial disease are strongly recommended against, as there is no evidence supporting their use. 1
Corticosteroid injections directed to local sites of musculoskeletal inflammation (sacroiliac joints, peripheral joints, entheses) may be considered for targeted symptom relief. 1, 2
Analgesics
- Analgesics such as paracetamol and opioid medications may be considered for residual pain only after NSAIDs have failed, are contraindicated, or are poorly tolerated. 1, 2
Management of Extra-Articular Manifestations
Frequently observed extra-articular manifestations (psoriasis, uveitis, inflammatory bowel disease) should be managed in collaboration with respective specialists. 1
Rheumatologists must be aware of increased cardiovascular disease and osteoporosis risk in AS patients. 1
Surgical Interventions
Total hip arthroplasty should be considered for patients with refractory pain or disability and radiographic evidence of structural damage, independent of age. 1
Spinal corrective osteotomy may be considered in patients with severe disabling deformity. 1
In patients with AS and acute vertebral fracture, immediate spinal surgeon consultation is required. 1
Disease Monitoring
Disease monitoring should include patient history (questionnaires), clinical parameters, laboratory tests, and imaging according to ASAS core set recommendations. 1
Frequency of monitoring depends on symptom course, severity, and treatment, but spinal radiographs should not be repeated more frequently than every 2 years unless specifically indicated. 1
Treatment Algorithm for Stable Disease
For patients with stable AS on TNF inhibitors, continue TNF inhibitor alone and stop NSAIDs to minimize side effects. 1
If on originator TNF inhibitor with stable disease, do not switch to biosimilar using a non-medical switching approach. 1
Common Pitfalls to Avoid
Do not delay TNF inhibitor initiation in patients with persistently high disease activity despite adequate NSAID trials, as early aggressive treatment improves long-term outcomes. 1, 6
Do not prescribe DMARDs (sulfasalazine, methotrexate) for axial symptoms, as they are ineffective for this manifestation. 1
Do not use etanercept in AS patients with inflammatory bowel disease; use monoclonal antibody TNF inhibitors instead. 1, 5
Do not use systemic corticosteroids for chronic axial disease management. 1