What are the initial treatment recommendations for a patient with ankylosing spondylitis?

Initial Treatment of Ankylosing Spondylitis

Start all patients with ankylosing spondylitis on NSAIDs as first-line pharmacological therapy combined with patient education and regular supervised exercise from the time of diagnosis. 1

First-Line Pharmacological Treatment

NSAIDs as Mandatory Initial Therapy

• NSAIDs (including COX-2 inhibitors) are the mandatory first-line drug treatment for all AS patients with pain and stiffness. 2, 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, peripheral joint pain, and function over short time periods (6 weeks). 2

NSAID Selection Based on Risk Profile

• For patients with elevated gastrointestinal risk: Use either non-selective NSAIDs plus a gastroprotective agent (PPIs reduce serious GI events by 60%) OR a selective COX-2 inhibitor (reduces serious GI events by 82% compared to traditional NSAIDs). 2, 1
• Always assess and account for cardiovascular, gastrointestinal, and renal risks when prescribing NSAIDs. 1
• Both traditional NSAIDs and COX-2 inhibitors demonstrate equivalent efficacy for spinal pain relief. 2

First-Line Non-Pharmacological Treatment

Exercise and Physical Therapy (Mandatory)

• Patient education and regular exercise form the cornerstone of non-pharmacological 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 significant reductions in disease activity (BASDAI: 1.13-1.17 lower), physical function (BASFI: 0.88-1.0 lower), and spinal mobility (BASMI: 0.7-1.35 lower) compared to standard care. 3
• Individual and group physical therapy should be considered, with patient associations and self-help groups potentially useful. 2

Treatment Algorithm

Step 1: Initial Assessment

Treatment must be tailored according to: 2

• Current manifestations (axial, peripheral, entheseal, extra-articular symptoms)
• Disease activity/inflammation levels
• Pain severity
• Functional status and disability
• Structural damage, hip involvement, spinal deformities
• General clinical status (age, sex, comorbidity, concomitant medications)
• Patient wishes and expectations

Step 2: Initiate Combined Therapy

• Start NSAIDs at full anti-inflammatory doses continuously (not on-demand). 1
• Simultaneously begin supervised exercise program (combined exercises or neuromuscular training preferred over conventional exercises). 3
• Provide patient education regarding disease nature, prognosis, and self-management strategies. 1

Step 3: Adjunctive Options for Inadequate Response

• Simple analgesics (acetaminophen, opioids) may be added for breakthrough pain when NSAIDs are insufficient or contraindicated. 2
• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be considered for peripheral arthritis or enthesitis. 2, 1
• Do NOT use systemic glucocorticoids for axial disease—there is no evidence of benefit. 2, 1

Step 4: When to Escalate to Biologic Therapy

• Anti-TNF therapy should be given to patients with persistently high disease activity despite adequate trials of NSAIDs and physical therapy. 1
• There is no evidence to support the obligatory use of DMARDs before or concomitant with anti-TNF therapy in patients with axial disease. 2, 1

What NOT to Do: Critical Pitfalls

DMARDs Have No Role in Axial Disease

• There is no evidence for the efficacy of DMARDs, including sulfasalazine and methotrexate, for the treatment of axial disease. 2, 1
• Sulfasalazine may be considered ONLY in patients with peripheral arthritis. 2, 1
• Do not require DMARD failure before initiating anti-TNF therapy in axial disease—this is not evidence-based. 1

Avoid Systemic Corticosteroids

• Systemic glucocorticoids for axial disease are not supported by evidence and should be avoided. 2, 1
• Only local corticosteroid injections for peripheral manifestations are appropriate. 2

Do Not Delay Biologic Therapy

• Do not delay anti-TNF therapy in patients with persistently high disease activity despite adequate NSAID trials and physical therapy. 1
• Patients who fail NSAIDs and exercise should be escalated promptly to biologics rather than attempting ineffective DMARDs. 1

Disease Monitoring Strategy

• Disease monitoring should include patient history (questionnaires), clinical parameters, laboratory tests, and imaging according to clinical presentation, as well as the ASAS core set. 2, 1
• The frequency of monitoring should be decided on an individual basis depending on symptoms, severity, and drug treatment. 2, 1
• Rheumatologists should be aware of the increased risk of cardiovascular disease and osteoporosis in AS patients. 1

Management of Extra-Articular Manifestations

• Frequently observed extra-articular manifestations should be managed in collaboration with respective specialists. 1
• Optimal management requires a combination of non-pharmacological and pharmacological treatments throughout the disease course. 2