From the Guidelines
Ankylosing spondylitis should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, and biologic medications such as tumor necrosis factor inhibitors (TNFi) should be used when activity persists despite NSAID treatment, as recommended by the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network in 2016 1.
Treatment Overview
The treatment of ankylosing spondylitis typically involves a combination of medications, physical therapy, and lifestyle modifications.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (500mg twice daily) or indomethacin (25mg 2-3 times daily) are commonly used as first-line therapy to manage pain and inflammation.
- For patients who don't respond adequately to NSAIDs, biologic medications such as TNF inhibitors (adalimumab 40mg every other week or etanercept 50mg weekly by subcutaneous injection) or IL-17 inhibitors (secukinumab 150mg weekly for 5 weeks, then monthly) are recommended 1.
Physical Therapy and Lifestyle Modifications
Physical therapy is essential in the management of ankylosing spondylitis, focusing on:
- Posture
- Breathing exercises
- Spine mobility to maintain function and prevent deformity Regular exercise, particularly swimming and stretching, helps maintain flexibility and reduce stiffness.
Disease Monitoring and Prevention
Patients with ankylosing spondylitis should be monitored regularly for disease progression and potential complications, including:
- Uveitis (eye inflammation)
- Cardiovascular issues
- Osteoporosis Early diagnosis and treatment are crucial to prevent spinal fusion and maintain quality of life, as emphasized by the ASAS/EULAR recommendations for the management of ankylosing spondylitis in 2006 1.
From the Research
Ankylosing Spondylitis Treatment
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for ankylosing spondylitis (AS) due to their rapid efficacy on inflammatory symptoms 2, 3, 4, 5.
- NSAIDs have been shown to be effective in reducing pain severity, improving patients' global assessment of disease activity, and reducing the rate of achieving an Assessment in Ankylosing Spondylitis 20% response (ASAS20) 4.
- Tumor necrosis factor (TNF) alpha inhibitors, such as infliximab, etanercept, and adalimumab, have been shown to improve spinal pain, function, inflammatory biomarkers, and spinal inflammation detected by magnetic resonance imaging in patients with AS 6, 3.
- Physical therapy and patient education are also useful for all patients diagnosed with AS, and can help maintain function and improve quality of life 6.
NSAID Efficacy and Safety
- A network meta-analysis of randomized controlled trials found that all NSAIDs were significantly more effective in reducing pain severity than placebo, with etoricoxib ranked as the most efficacious treatment for patients with AS 4.
- The safety endpoints of NSAIDs, including total adverse events, gastrointestinal adverse events, withdrawals due to adverse events, and serious adverse events, were found to be similar to those of placebo, except for diclofenac and naproxen which had a higher risk of gastrointestinal events 4.
- The long-term safety profile of NSAIDs needs to be proven, particularly with regards to gastrointestinal toxicity 5.
Disease Management
- The objective of treatment is to control symptoms, maintain function, and improve quality of life, with a focus on early recognition and diagnosis of AS 3.
- MRI may be useful in evaluating early disease, although chronic changes of sacroiliitis are better seen on plain X-rays 3.
- Regular use of NSAIDs among patients with AS may slow radiographic progression, and TNF inhibitor therapy has improved quality of life for patients with an inadequate response to NSAIDs 3.