Systemic Steroids Have No Role in Axial Ankylosing Spondylitis
Systemic glucocorticoids (such as oral prednisone) are not supported by evidence for treating axial disease in ankylosing spondylitis and should not be used for acute flare-ups of spinal symptoms. 1
Evidence-Based Treatment Algorithm
For Axial Disease (Spinal Symptoms)
- NSAIDs are first-line therapy for pain and stiffness in AS, with continuous treatment preferred for persistently active disease 1
- If NSAIDs fail or are contraindicated, proceed directly to analgesics (paracetamol, opioids) for residual pain 1
- For persistently high disease activity despite NSAIDs, initiate anti-TNF therapy (etanercept, infliximab, adalimumab, certolizumab, golimumab) 1, 2
- Skip systemic steroids entirely - there is no evidence supporting their use for axial manifestations 1
For Localized Inflammation
- Corticosteroid injections directed to the local site may be considered for specific situations 1:
- Intra-articular or periarticular injections for sacroiliitis (level Ib evidence showing pain improvement) 1
- Peripheral joint injections for oligoarthritis
- Periarticular injections for enthesitis (though evidence is limited)
Important Caveats
The FDA label for prednisone lists AS as an indication 3, but this conflicts with current evidence-based guidelines. The FDA indication states prednisone may be used "as adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation)" in AS 3. However, the ASAS/EULAR guidelines explicitly state that systemic glucocorticoid use for axial disease is not supported by evidence 1.
One small 2016 study showed low-dose modified-release prednisone (5 mg nightly) reduced BASDAI scores in 57 GC-naïve patients with symptomatic axial SpA, with 52.6% response rate 4. However, this single retrospective cohort study does not override the consistent guideline recommendations against systemic steroids based on lack of quality evidence 1.
Intravenous methylprednisolone has been described as useful in recalcitrant cases of severe, active AS (level IV evidence only), but no studies have evaluated oral corticosteroid treatment 1.
Clinical Pitfalls to Avoid
- Do not prescribe oral prednisone for axial flares - it lacks evidence and exposes patients to steroid side effects without proven benefit 1
- Do not confuse peripheral arthritis with axial disease - sulfasalazine may help peripheral joints but not spinal symptoms 1
- Do not delay anti-TNF therapy in patients with persistently high disease activity despite NSAIDs - there is no requirement to trial DMARDs first for axial disease 1, 2
- Consider local steroid injections for sacroiliitis or peripheral joint involvement, which have demonstrated efficacy 1
Why Systemic Steroids Don't Work
The pathophysiology of AS involves localized inflammation at entheses and joints rather than systemic inflammation responsive to oral corticosteroids 1. The ASAS/EULAR recommendations from 2006 and updated in 2011 consistently emphasize that no studies evaluating oral corticosteroid treatment in AS have been published 1, and the expert consensus strongly advises against their use 1.