What is the recommended treatment for a patient with ankylosing spondylitis?

Recommended Treatment for Ankylosing Spondylitis

Start with NSAIDs as first-line pharmacological therapy combined with regular supervised exercise, and escalate to TNF inhibitors if disease activity remains high despite 4 weeks of maximum-dose NSAID therapy and physical therapy. 1

Initial Non-Pharmacological Management

Patient education and regular exercise form the cornerstone of AS treatment and must be initiated immediately at diagnosis. 1

• Supervised group physiotherapy (land or water-based) is superior to home exercises alone and should be prescribed rather than simply recommending unsupervised home programs. 1, 2
• Supervised exercise programs demonstrate better patient global assessment scores and greater improvements in spinal mobility (7.5-18% relative improvement) compared to home exercises. 2
• Physical therapy should continue throughout the disease course regardless of pharmacological treatment status. 1

First-Line Pharmacological Treatment

NSAIDs (including COX-2 inhibitors) are the first-line drug treatment for all AS patients with pain and stiffness. 1

• Continuous daily NSAID therapy is preferred over on-demand use in patients with persistently active symptomatic disease, as continuous treatment may retard radiographic progression. 1
• No single NSAID has proven superior efficacy; selection should be based on individual patient tolerability and risk factors. 1
• For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus a proton pump inhibitor (reduces serious GI events by 60%) or selective COX-2 inhibitors (reduces serious GI events by 82%). 1
• Cardiovascular, gastrointestinal, and renal risks must be assessed before prescribing NSAIDs, particularly in patients with pre-existing cardiovascular disease or renal impairment. 1

Second-Line Pharmacological Options

If NSAIDs are insufficient, contraindicated, or poorly tolerated, add analgesics (paracetamol or opioids) for breakthrough pain control. 1

Local corticosteroid injections may be used for isolated sites of musculoskeletal inflammation (sacroiliitis, enthesitis, or peripheral arthritis). 1

• Systemic glucocorticoids have no evidence supporting their use for axial disease and should be avoided. 1

Disease-Modifying Antirheumatic Drugs (DMARDs)

Traditional DMARDs (sulfasalazine, methotrexate) have no efficacy for axial disease and should not be used for this indication. 1

• Sulfasalazine may be considered only in patients with concomitant peripheral arthritis. 1

Biologic Therapy: TNF Inhibitors

Anti-TNF therapy (adalimumab, etanercept, infliximab) should be initiated in patients with persistently high disease activity despite 4 weeks of maximum-dose NSAID therapy and physical therapy. 1, 3, 4

• There is no requirement to trial DMARDs before initiating TNF inhibitors for axial disease. 1
• All three TNF inhibitors show equivalent efficacy for axial and peripheral manifestations; however, monoclonal antibodies (adalimumab, infliximab) may be preferred over etanercept in patients with concomitant inflammatory bowel disease due to superior gastrointestinal efficacy. 1
• Switching to a second TNF inhibitor is beneficial in patients who lose response to the first agent. 1
• The recommended dosing for adalimumab is 40 mg subcutaneously every other week. 3
• The recommended dosing for etanercept is 50 mg subcutaneously weekly. 4

Prior to initiating TNF inhibitor therapy, screen for latent tuberculosis and active infections, as these agents significantly increase infection risk including TB reactivation. 3, 4

Management of Extra-Articular Manifestations

Collaborate with specialists for management of extra-articular manifestations including uveitis (ophthalmology), psoriasis (dermatology), and inflammatory bowel disease (gastroenterology). 1

Monitor for increased cardiovascular disease risk and osteoporosis, which occur at higher rates in AS patients. 1

Surgical Intervention

Total hip arthroplasty should be considered in patients with refractory hip pain or disability with radiographic evidence of structural damage, regardless of patient age. 1

Spinal corrective osteotomy may be considered for patients with severe disabling deformity. 1

Common Pitfalls to Avoid

• Do not delay TNF inhibitor therapy in patients with persistently high disease activity despite adequate NSAID and physical therapy trials—early aggressive treatment improves long-term outcomes. 1
• Do not prescribe traditional DMARDs (sulfasalazine, methotrexate) for axial symptoms—they are ineffective for spinal disease. 1
• Do not use systemic corticosteroids for axial disease management—evidence does not support their use. 1
• Do not recommend home exercises alone—supervised group physiotherapy produces superior outcomes. 1, 2
• Do not use intermittent on-demand NSAID therapy in patients with persistently active disease—continuous therapy is more effective. 1