Initial Treatment of Ankylosing Spondylitis
NSAIDs are the mandatory first-line pharmacological treatment for all patients with ankylosing spondylitis who have pain and stiffness, and should be combined with patient education and regular supervised exercise from the time of diagnosis. 1
First-Line Treatment Algorithm
Non-Pharmacological Foundation (Start Immediately)
- Patient education and regular exercise form the cornerstone of treatment and must be implemented from diagnosis onward 1
- Supervised physical therapy is more effective than home exercises alone and should be preferred 1
- Supervised combined exercises and neuromuscular training show the most significant improvements in disease activity (BASDAI reduction of 1.13-1.17 points), physical function (BASFI reduction of 0.88-1.0 points), and spinal mobility (BASMI reduction of 0.7-1.35 points) compared to standard care 2
- Individual and group physical therapy should both be considered, with group therapy showing significantly better patient global assessment compared to home exercise alone 3
First-Line Pharmacological Treatment
- NSAIDs (including COX-2 inhibitors) are recommended as first-line drug treatment for all patients with pain and stiffness 3, 1
- Continuous NSAID treatment is preferred over on-demand dosing for patients with persistently active, symptomatic disease 1
- NSAIDs demonstrate convincing level Ib evidence for improving spinal pain and function over short time periods (6 weeks) 3
- Both traditional NSAIDs and COX-2 inhibitors demonstrate equivalent efficacy for spinal pain relief 3
NSAID Selection Based on Risk Profile
- For patients with increased gastrointestinal risk: use non-selective NSAIDs plus a gastroprotective agent (PPIs reduce serious GI events by 60%, RR 0.40), or a selective COX-2 inhibitor (reduces serious GI events by 82% compared to traditional NSAIDs, RR 0.18) 3, 1
- Assess and account for cardiovascular, gastrointestinal, and renal risks when prescribing NSAIDs 1
Treatment Monitoring Strategy
- Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation, as well as the ASAS core set 3, 1
- Frequency of monitoring should be decided individually depending on symptoms, severity, and drug treatment 3, 1
Second-Line Options (If NSAIDs Insufficient)
For Residual Pain
- Simple analgesics (acetaminophen, opioids) may be added for breakthrough pain when NSAIDs are insufficient, contraindicated, or poorly tolerated 3, 1
For Peripheral Manifestations
- Corticosteroid injections directed to local sites of musculoskeletal inflammation may be considered for peripheral arthritis or enthesitis 3, 1
- Sulfasalazine may be considered only in patients with peripheral arthritis—there is no evidence for efficacy in axial disease 3, 1
Critical Pitfalls to Avoid
- Do not use systemic corticosteroids for axial disease—there is no evidence of benefit 3, 1
- Do not prescribe DMARDs (including sulfasalazine and methotrexate) for axial symptoms—they are ineffective for spinal disease 3, 1
- Do not use on-demand NSAID dosing in patients with persistently active disease—continuous treatment is superior 1
- Do not neglect cardiovascular risk assessment, as AS patients have increased cardiovascular disease risk 1
When to Escalate to Anti-TNF Therapy
- Anti-TNF therapy should be given to patients with persistently high disease activity despite adequate trials of NSAIDs and physical therapy 3, 1
- There is no evidence to support the obligatory use of DMARDs before or concomitant with anti-TNF therapy in patients with axial disease 3, 1
- For ankylosing spondylitis, infliximab is dosed at 5 mg/kg IV at weeks 0,2, and 6, then every 6 weeks for maintenance 4
- Etanercept is dosed at 50 mg subcutaneously weekly for ankylosing spondylitis 5