Recent Advances in Management of Ankylosing Spondylitis
The most significant recent advance in AS management is the introduction of anti-TNF biological therapy for patients with persistently high disease activity despite NSAIDs, which has revolutionized treatment outcomes for refractory disease. 1
First-Line Treatment: NSAIDs
NSAIDs remain the cornerstone first-line pharmacological treatment for AS patients with pain and stiffness, with level Ib evidence demonstrating improvement in spinal pain, peripheral joint pain, and function over 6 weeks. 1
Continuous NSAID treatment is preferred over intermittent "on-demand" use for patients with persistently active, symptomatic disease, as emerging evidence suggests continuous treatment may retard radiographic disease progression at 2 years. 1
Among NSAIDs, etoricoxib ranks as the most efficacious treatment based on network meta-analysis, though all NSAIDs show significant efficacy. 2
For patients with increased gastrointestinal risk, prescribe either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor. 1
Critical caveat: Cardiovascular and renal risks must be assessed before prescribing NSAIDs, as emerging evidence suggests both coxibs and traditional NSAIDs may carry cardiovascular toxicity. 1
Non-Pharmacological Treatment Foundation
Patient education and regular exercise should be initiated immediately and continued throughout the disease course, as level Ib evidence supports home exercise improving function in the short term. 1
Group physical therapy demonstrates better patient global assessment outcomes compared to home exercise alone, though both improve function. 1
Spa therapy shows cost-effective benefits for physical functioning over 3 months. 1
Biological Therapy: The Major Advance
Anti-TNF therapy should be initiated in patients with persistently high disease activity despite conventional NSAID treatment, following ASAS recommendations. 1
There is no evidence requiring DMARD use before or concomitant with anti-TNF therapy for axial disease—this represents a key advance allowing direct escalation to biologics. 1
All TNF inhibitors (infliximab, etanercept, adalimumab) show equivalent efficacy for axial and articular/entheseal manifestations, with level Ib evidence supporting large treatment effects over at least 6 months. 1
For patients with concurrent inflammatory bowel disease, monoclonal antibody anti-TNF agents (infliximab, adalimumab) are strongly preferred over etanercept due to differences in gastrointestinal efficacy. 1, 3
Switching to a second TNF blocker may be beneficial, especially in patients with loss of response to the first agent. 1
What NOT to Use for Axial Disease
DMARDs including sulfasalazine and methotrexate have no evidence of efficacy for axial disease treatment—this is a critical advance in understanding. 1
Sulfasalazine may be considered only for patients with peripheral arthritis, not axial symptoms. 1
Systemic corticosteroids for axial disease are not supported by evidence. 1
Local corticosteroid injections directed to specific sites of musculoskeletal inflammation may be considered for targeted treatment. 1
Surgical Interventions
Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age. 1
Spinal corrective osteotomy may be considered for patients with severe disabling deformity. 1
In patients with acute vertebral fracture, immediate spinal surgeon consultation is mandatory. 1
Disease Monitoring Advances
Disease monitoring should include patient history (questionnaires), clinical parameters, laboratory tests, and imaging according to the ASAS core set. 1
Spinal radiographs should not be repeated more frequently than every 2 years unless clearly indicated in individual cases—this represents an evidence-based advance in reducing unnecessary radiation exposure. 1
Assessment must evaluate disease activity/inflammation, pain levels, function, disability, structural damage, and comorbidities. 1, 4
Management of Extra-Articular Manifestations
Extra-articular manifestations including uveitis, inflammatory bowel disease, and vascularitis must be managed in collaboration with respective specialists. 1, 3
For patients with vascularitis, anti-TNF agents are particularly indicated as they can treat both AS and vasculitic manifestations simultaneously. 3
Key Pitfalls to Avoid
Do not delay anti-TNF therapy by requiring failed DMARD trials first—this outdated approach is not evidence-based for axial disease. 1
Do not prescribe sulfasalazine or methotrexate for purely axial symptoms—reserve these only for peripheral arthritis. 1
Do not use NSAIDs intermittently if disease is persistently active—continuous treatment is superior and may slow radiographic progression. 1
When significant disease course changes occur, consider non-inflammatory causes such as spinal fracture and perform appropriate imaging evaluation. 1