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

Treatment of Ankylosing Spondylitis

Start all patients with NSAIDs as first-line therapy, escalate to TNF inhibitors if disease remains active despite adequate NSAID trials, and reserve IL-17 inhibitors (secukinumab or ixekizumab) for TNF inhibitor failures. 1, 2

First-Line Treatment: NSAIDs

NSAIDs are the cornerstone of initial pharmacological management for all patients with active ankylosing spondylitis. 1, 2

• Begin NSAID therapy immediately at the lowest effective dose for patients experiencing pain and stiffness 2, 3
• High-quality evidence demonstrates NSAIDs improve spinal pain, peripheral joint pain, and function over 6 weeks 2
• If the first NSAID fails after 2-4 weeks, switch to a different NSAID before declaring NSAID failure 3
• Continuous NSAID therapy is preferred over on-demand dosing for patients with persistently active disease, as emerging evidence suggests it may slow radiographic progression 1, 2
• No particular NSAID is superior to others; selection should be based on individual tolerability 1
• For patients with gastrointestinal risk, prescribe either non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 2

Essential Non-Pharmacological Treatment

Physical therapy and regular exercise must be initiated immediately at diagnosis and continued throughout the disease course. 1, 2

• Refer all patients to a structured exercise program at diagnosis 3
• Group physical therapy demonstrates superior outcomes compared to home exercise alone (Level Ib evidence) 2
• Home exercises remain effective and should be recommended to all patients 3

Second-Line Treatment: TNF Inhibitors

Initiate TNF inhibitor therapy when disease activity remains high despite adequate trials of at least two different NSAIDs. 1, 2

• This recommendation carries high-quality evidence and represents a strong recommendation 1
• All TNF inhibitors (infliximab, etanercept, adalimumab, certolizumab, golimumab, and biosimilars) show equivalent efficacy for axial and peripheral manifestations 1, 2
• Critical exception: For patients with concomitant inflammatory bowel disease or recurrent uveitis, use TNF inhibitor monoclonal antibodies (infliximab, adalimumab, certolizumab, golimumab) rather than etanercept 1, 2
• TNF inhibitors are conditionally preferred over IL-17 inhibitors as the initial biologic choice 1

Third-Line Treatment: IL-17 Inhibitors

For patients with active disease despite first TNF inhibitor use, switch to IL-17 inhibitors (secukinumab or ixekizumab). 1, 4

• Secukinumab is FDA-approved for active ankylosing spondylitis in adults 4
• IL-17 inhibitors are conditionally recommended over sulfasalazine, methotrexate, or tofacitinib after TNF inhibitor failure 1
• High-quality evidence supports secukinumab and ixekizumab over no treatment in NSAID-refractory patients 1

What NOT to Do

Avoid systemic glucocorticoids for axial disease—they lack efficacy and cause significant side effects. 1, 2

• Conventional synthetic DMARDs (sulfasalazine, methotrexate) have no proven efficacy for axial disease and should not be used as monotherapy 2
• These agents should only be considered in patients with prominent peripheral arthritis or when TNF inhibitors are unavailable 1
• Do not add methotrexate to TNF inhibitors (conditionally recommended against) 2
• Tofacitinib is conditionally recommended only when TNF inhibitors are not available, and is inferior to both TNF inhibitors and IL-17 inhibitors 1

Surgical Considerations

Consider total hip arthroplasty for patients with refractory pain or disability and radiographic evidence of advanced hip arthritis, independent of age. 1, 2

• Spinal corrective osteotomy may be considered for severe disabling deformity 2

Common Pitfalls to Avoid

• Do not exclude ankylosing spondylitis based solely on negative HLA-B27, normal CRP, or normal ESR 3
• Do not delay referral to rheumatology—typical diagnostic delay is 5-7 years from symptom onset 3
• Do not use analgesics (paracetamol, opioids) except for residual pain after failure of recommended treatments 3
• Ensure patients complete age-appropriate vaccinations before initiating biologic therapy 4
• Screen for active or latent tuberculosis before starting TNF inhibitors or IL-17 inhibitors 4