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 exercise from the time of diagnosis. 1, 2
Treatment Algorithm
First-Line Therapy (All Patients)
Pharmacological:
- Start NSAIDs (including COX-2 inhibitors) immediately for symptomatic patients with pain and stiffness 3, 1, 2
- Use continuous daily dosing rather than on-demand dosing for patients with persistently active disease, as emerging evidence suggests continuous treatment may retard radiographic progression at 2 years 2
- For patients with gastrointestinal risk factors, prescribe either:
- Assess cardiovascular, gastrointestinal, and renal risks before prescribing NSAIDs 1
Non-Pharmacological (Mandatory):
- Initiate patient education immediately at diagnosis 1, 2
- Prescribe regular exercise programs—home exercises improve function with level Ib evidence 1, 2
- Supervised group physical therapy is superior to home exercise alone for patient global assessment outcomes, though both improve function similarly 1, 2
Second-Line Options (If NSAIDs Insufficient)
- Add simple analgesics (acetaminophen or opioids) for breakthrough pain when NSAIDs are insufficient, contraindicated, or poorly tolerated 3, 1
- Consider local corticosteroid injections for peripheral arthritis or enthesitis 1, 2
- Do NOT use systemic corticosteroids for axial disease—there is no evidence of benefit 3, 1, 2
Disease-Modifying Drugs (Limited Role)
- Do NOT prescribe conventional DMARDs (sulfasalazine, methotrexate) for axial symptoms—they are completely ineffective for spinal disease 3, 1, 2
- Sulfasalazine may be considered ONLY in patients with peripheral arthritis 3, 1, 2
Biologic Therapy (For Refractory Disease)
- Initiate anti-TNF therapy (etanercept 4, adalimumab 5, or infliximab) in patients with persistently high disease activity despite adequate trials of NSAIDs and physical therapy 3, 1, 2
- Do NOT require DMARD failure before starting anti-TNF therapy in axial disease—this is not evidence-based and delays effective treatment 3, 1, 2
- Anti-TNF agents can be used as monotherapy without concomitant DMARDs for axial disease 3, 1, 2
- All TNF inhibitors show equivalent efficacy with level Ib evidence supporting large treatment effects over at least 6 months 2
Disease Monitoring Strategy
- Monitor using patient history (questionnaires), clinical parameters, laboratory tests, and imaging according to the ASAS core set 3, 1, 2
- Individualize monitoring frequency based on symptoms, severity, and current drug treatment 3, 1, 2
- Do not repeat spinal radiographs more frequently than every 2 years unless clearly indicated 2
Management of Extra-Articular Manifestations
- Collaborate with specialists for extra-articular manifestations including uveitis, inflammatory bowel disease, and cardiovascular complications 1, 2
- Screen for increased cardiovascular disease risk and osteoporosis, which are more prevalent in AS patients 1
Surgical Considerations
- Consider total hip arthroplasty for refractory pain or disability with radiographic evidence of structural damage, regardless of patient age 3, 1, 2
- Spinal corrective osteotomy may be considered for severe disabling deformity 1, 2
Critical Pitfalls to Avoid
- Do not delay anti-TNF therapy in patients with persistently high disease activity despite adequate NSAID trials and physical therapy—this is the most common error in AS management 1
- Do not prescribe systemic corticosteroids for axial disease—no evidence supports this practice 3, 1, 2
- Do not use conventional DMARDs for axial symptoms—they provide no benefit for spinal disease 3, 1, 2
- Do not require DMARD failure before initiating anti-TNF therapy in axial disease—this outdated approach delays effective treatment 3, 1, 2
- Do not use NSAIDs intermittently in patients with persistently active disease—continuous dosing is preferred and may slow radiographic progression 2