What are the treatment options for Ankylosing Spondylitis (AS)?

From the Guidelines

Treatment for Ankylosing Spondylitis (AS) should prioritize nonsteroidal anti-inflammatory drugs (NSAIDs) as the first-line treatment, followed by tumor necrosis factor inhibitors (TNFi) if NSAIDs are insufficient, as recommended by the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 1.

Key Recommendations

• NSAIDs are the first-line treatment for AS, with a strong recommendation for their use over no treatment with NSAIDs 1.
• TNFi are recommended if NSAIDs are insufficient, with a strong recommendation for their use over no treatment with TNFi 1.
• IL-17 inhibitors such as secukinumab or ixekizumab are also recommended if NSAIDs and TNFi are insufficient, with a strong recommendation for their use over no treatment with these medications 1.
• Physical therapy and lifestyle modifications are also important components of AS treatment, with a focus on maintaining good posture, using appropriate mattresses and pillows, quitting smoking, and avoiding prolonged inactivity.

Treatment Approach

The treatment approach for AS should be personalized, taking into account the individual patient's needs and response to treatment. The goal of treatment is to reduce inflammation, prevent fusion of vertebrae, and maintain mobility. Regular monitoring of disease progression through imaging and blood tests (ESR, CRP) is important to adjust treatment as needed.

Medication Options

• NSAIDs: naproxen (500mg twice daily) or indomethacin (25mg 2-3 times daily) are commonly used NSAIDs for AS treatment.
• TNFi: adalimumab (40mg subcutaneously every other week), etanercept (50mg subcutaneously weekly), or infliximab (5mg/kg intravenously every 6-8 weeks) are commonly used TNFi for AS treatment.
• IL-17 inhibitors: secukinumab (150mg subcutaneously weekly for 5 weeks, then monthly) or ixekizumab (80mg subcutaneously every 4 weeks) are commonly used IL-17 inhibitors for AS treatment.

Lifestyle Modifications

• Maintain good posture: use appropriate mattresses and pillows to support the spine.
• Quit smoking: smoking can exacerbate AS symptoms and reduce treatment effectiveness.
• Avoid prolonged inactivity: regular exercise, such as swimming, can help maintain mobility and reduce stiffness.
• Heat therapy: can help relieve stiffness and reduce pain.

From the FDA Drug Label

1. 4 Ankylosing Spondylitis Enbrel is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis (AS).
2. 3 Recommended Dosage in Adult Patients with Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, and Plaque Psoriasis Enbrel is administered by subcutaneous injection (Table 1). Table 1 Recommended Dosage for Adult Patients with RA, AS, PsA and PsO Patient PopulationRecommended Dosage Adult RA, AS, and PsA50 mg weekly

The treatment for Ankylosing Spondylitis (AS) is etanercept (Enbrel), administered by subcutaneous injection at a recommended dosage of 50 mg weekly 2.

From the Research

Treatment Options for Ankylosing Spondylitis (AS)

• The primary goal of treatment is to reduce pain, stiffness, and discomfort, and can be achieved through various pharmacological and non-pharmacological methods 3, 4, 5.
• There are three main groups of drugs used in the management of AS:
  • Drugs that influence the disease process itself, such as sulfasalazine 3, 5.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) that suppress inflammation without influencing the disease process 3, 4, 5, 6.
  • Analgesics and muscle relaxants that can be used as adjuvant therapy 3, 5.

Pharmacological Treatment

• Sulfasalazine is recommended for patients with high disease activity, peripheral arthritis, and those with AS of short duration 3.
• NSAIDs should be administered selectively during periods of high disease activity, and high doses may be prescribed before bedtime in patients suffering from severe pain and stiffness during the night 3.
• Tumor necrosis factor (TNF) alpha inhibitors, such as infliximab, etanercept, and adalimumab, have been shown to improve spinal pain, function, and inflammatory biomarkers in patients with AS 4, 7.
• Biological therapies, such as TNF blockers, may be considered as a first-line treatment for AS patients whose condition is not sufficiently controlled with NSAIDs 7.

Non-Pharmacological Treatment

• Physical therapy and patient education have been shown to be effective in maintaining function in AS patients 4.
• A program of physical exercise and physiotherapy can help reduce stiffness and spinal ankylosis, and improve the patient's quality of life 5.

Safety and Efficacy of NSAIDs

• A network meta-analysis of randomized controlled trials found that all NSAIDs were significantly more effective in reducing pain severity than placebo, and that etoricoxib was ranked as the most efficacious treatment for patients with AS 6.
• However, patients treated with diclofenac and naproxen had a higher risk of gastrointestinal events than those taking placebo 6.