Treatment of Ankylosing Spondylitis
NSAIDs are the first-line pharmacological treatment for all patients with active AS, and should be used continuously rather than on-demand in patients with persistently active disease, followed by TNF inhibitors for those with inadequate response. 1, 2
Initial Treatment Approach
Non-Pharmacological Management (Start Immediately)
- Patient education and regular exercise must be initiated at diagnosis and continued throughout the disease course, as level Ib evidence demonstrates improvement in function 2
- Group physical therapy shows superior patient global assessment outcomes compared to home exercise alone, though both improve function 2, 3
First-Line Pharmacological Treatment
- NSAIDs are strongly recommended as the cornerstone first-line drug treatment for patients with pain and stiffness, with high-quality evidence showing improvement in spinal pain, peripheral joint pain, and function over 6 weeks 1, 2
- Continuous NSAID therapy is conditionally recommended over on-demand use in patients with persistently active, symptomatic disease, as emerging evidence suggests continuous treatment may retard radiographic disease progression at 2 years 1, 2
- No particular NSAID is preferred over another—the choice should be based on individual patient tolerability and response 1
- For patients with increased gastrointestinal risk, prescribe either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1, 2
Second-Line Treatment for Active Disease Despite NSAIDs
Biologic Therapy (Preferred)
- TNF inhibitors are strongly recommended for patients with persistently high disease activity despite NSAID treatment, with high-quality evidence supporting their efficacy 1, 2, 4, 5
- All TNF inhibitors (infliximab, etanercept, adalimumab, certolizumab, golimumab) show equivalent efficacy—no particular TNFi is preferred 1, 2
- There is no evidence requiring DMARD use before or concomitant with anti-TNF therapy for axial disease 1, 2
- For adults with active AS despite NSAIDs, the dosing is:
IL-17 Inhibitors (Alternative Biologics)
- Secukinumab or ixekizumab are strongly recommended over no treatment for patients with active AS despite NSAIDs, with high-quality evidence 1
- TNF inhibitors are conditionally recommended over IL-17 inhibitors as the preferred biologic choice, though the evidence quality is very low 1
- IL-17 inhibitors are conditionally recommended over tofacitinib 1
Conventional DMARDs (Limited Role)
- Sulfasalazine or methotrexate should be considered ONLY in patients with prominent peripheral arthritis or when TNFi are not available—they have no proven efficacy for axial disease 1
- Tofacitinib is conditionally recommended but is inferior to TNF inhibitors 1
Treatment After First TNF Inhibitor Failure
- Secukinumab or ixekizumab are conditionally recommended over switching to sulfasalazine, methotrexate, or tofacitinib 1
- Switching to another TNF inhibitor is also a reasonable option, as no particular TNFi is superior 1
Adjunctive Therapies
- Analgesics (paracetamol, opioids) may be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
- Corticosteroid injections directed to local sites of musculoskeletal inflammation (sacroiliac joints, entheses, peripheral joints) may be considered 1, 3
- Systemic corticosteroids for axial disease are NOT supported by evidence 1
Disease Monitoring
- Monitor using patient history (questionnaires), clinical parameters, laboratory tests, and imaging according to the ASAS core set 1, 3
- Spinal radiographs should not be repeated more frequently than every 2 years unless clearly indicated 2, 3
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, 3
- Spinal corrective osteotomy and stabilization procedures may be valuable in selected patients with severe disabling deformity 1, 3
Critical Safety Considerations
- Before initiating TNF inhibitors, test for latent tuberculosis and evaluate for active infection—discontinue if serious infection develops 4, 5
- TNF inhibitors carry increased risk of serious infections, reactivation of latent tuberculosis, and malignancies including lymphoma 4, 5
- NSAIDs carry significant gastrointestinal, cardiovascular, and renal toxicity risks, particularly with long-term continuous use 1
- Complete age-appropriate vaccinations before initiating TNF inhibitor therapy 4