What is the recommended use of steroids (corticosteroids) in a patient with ankylosing spondylitis, particularly considering potential risks such as osteoporosis, glucose intolerance, and cardiovascular disease?

Steroids in Ankylosing Spondylitis

Systemic corticosteroids should be strongly avoided for axial disease in ankylosing spondylitis, while local corticosteroid injections may be used selectively for peripheral manifestations. 1

Systemic Corticosteroids: Not Recommended

The use of systemic glucocorticoids for axial disease is not supported by evidence and is strongly recommended against. 1 This represents a Grade A recommendation from both ASAS/EULAR and ACR/SAA/SPARTAN guidelines, despite being based on very low quality evidence—the strength of the recommendation reflects the lack of efficacy data combined with well-established risks. 1

The rationale for avoiding systemic steroids is multifactorial:

• No demonstrated efficacy: There are no controlled trials showing benefit for axial symptoms, which constitute the primary disease manifestation in AS. 1
• Significant comorbidity burden: Patients with AS already face increased risks of osteoporosis and cardiovascular disease—two conditions that systemic corticosteroids directly worsen. 1, 2
• Bone health concerns: Corticosteroids decrease bone formation and increase bone resorption through effects on calcium regulation and osteoblast inhibition, particularly problematic given that AS patients already have elevated osteoporosis risk. 2
• Metabolic complications: The FDA label for prednisone explicitly warns about glucose intolerance, sodium retention with edema, and cardiovascular effects—all relevant to the AS population. 2

Local Corticosteroid Injections: Conditionally Recommended

Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered for specific peripheral manifestations. 1

Appropriate Use Cases:

• Isolated active sacroiliitis despite NSAIDs: Conditionally recommend locally administered parenteral glucocorticoids (very low quality evidence). 1
• Active peripheral arthritis with stable axial disease despite NSAIDs: Conditionally recommend intra-articular glucocorticoids. 1
• Active enthesitis with stable axial disease despite NSAIDs: Conditionally recommend local glucocorticoids. 1

Critical Safety Caveat:

Peri-tendon injections of Achilles, patellar, and quadriceps tendons must be avoided due to rupture risk. 1, 3 This represents a specific contraindication even when local steroid therapy is otherwise appropriate. 3

Small RCTs have demonstrated level Ib evidence for efficacy of intra-articular or periarticular corticosteroid injections for sacroiliac joint pain, though no studies exist for peripheral arthritis or enthesitis specifically in AS. 1

Recommended Treatment Algorithm

First-line therapy: NSAIDs (including COX-2 inhibitors) for pain and stiffness, with continuous treatment preferred over on-demand use for persistently active disease. 1

Second-line for axial disease: Anti-TNF therapy for persistently high disease activity despite conventional treatments—not systemic corticosteroids. 1

For peripheral manifestations only: Consider local corticosteroid injections to specific inflamed sites (avoiding peri-tendon areas), while sulfasalazine may be added for peripheral arthritis. 1

Comorbidity management: Given the increased cardiovascular and osteoporosis risk in AS, rheumatologists must actively screen for and manage these conditions rather than adding systemic corticosteroids that would exacerbate both. 1

Common Pitfalls

Do not use oral corticosteroids as a bridge to biologic therapy—this practice lacks evidence and exposes patients to unnecessary risks. 1 The guidelines explicitly state there is no evidence to support obligatory DMARD use before anti-TNF therapy, and the same principle applies to corticosteroids. 1

Do not inject corticosteroids into or around the Achilles tendon insertion—this carries significant rupture risk even when treating legitimate enthesitis. 1, 3

Do not overlook the osteoporosis risk—if systemic corticosteroids are used for any reason (such as extra-articular manifestations managed by other specialists), bone protection strategies including calcium, vitamin D, bisphosphonates, and weight-bearing exercise must be implemented for any patient anticipated to receive ≥5 mg prednisone equivalent for ≥3 months. 2