What is the appropriate treatment for a patient with ankylosing spondylitis (AS)?

Treatment of Ankylosing Spondylitis

For active ankylosing spondylitis, initiate NSAIDs as first-line therapy combined with physical therapy; if inadequate response after an appropriate trial, escalate to TNF inhibitor therapy. 1

First-Line Treatment: NSAIDs + Physical Therapy

NSAIDs

• Start NSAIDs immediately for all patients with active AS presenting with pain and stiffness. 1, 2
• No specific NSAID is superior to others—select based on the patient's gastrointestinal and cardiovascular risk profile. 1, 2
• Use continuous daily dosing rather than on-demand dosing for patients with persistently active disease, as continuous treatment may retard radiographic progression. 1, 3

NSAID Selection Based on Risk Profile

• For patients with elevated GI risk (age >65, prior GI bleeding, concurrent corticosteroids): prescribe either a COX-2 selective inhibitor OR a non-selective NSAID plus proton pump inhibitor. 1, 2
• For patients with cardiovascular risk factors: carefully weigh risks as both COX-2 inhibitors and traditional NSAIDs carry cardiovascular toxicity. 1, 4

Physical Therapy

• Initiate physical therapy concurrently with NSAIDs—this is mandatory, not optional. 1
• Supervised group physical therapy is superior to home exercise alone and should be the preferred approach. 1, 3
• Emphasize active interventions (patient-performed exercises) over passive modalities. 1

Second-Line Treatment: TNF Inhibitors

When to Escalate

• Initiate TNF inhibitor therapy when disease remains persistently active despite adequate NSAID trial and physical therapy. 1, 3
• Do NOT require DMARD failure before starting TNF inhibitors—DMARDs have no proven efficacy for axial disease. 3, 4

TNF Inhibitor Selection

• All TNF inhibitors are equally effective for AS, with two critical exceptions: 1
  • For patients with concurrent inflammatory bowel disease: use monoclonal antibody TNF inhibitors (infliximab, adalimumab, golimumab) NOT etanercept, as etanercept may worsen IBD. 1
  • For patients with recurrent uveitis: consider monoclonal antibodies over etanercept. 1

TNF Inhibitor Dosing

• Etanercept: 50 mg subcutaneously weekly for AS. 5
• Continue NSAIDs or discontinue based on symptom control—no requirement for concurrent DMARD therapy in axial disease. 1, 3

Treatments to AVOID

Systemic Glucocorticoids

• Do NOT use systemic corticosteroids for axial AS—there is no evidence of benefit and strong recommendation against their use. 1

DMARDs (Sulfasalazine, Methotrexate)

• Do NOT prescribe sulfasalazine or methotrexate for axial symptoms—they are completely ineffective for spinal disease. 3, 4
• Sulfasalazine may be considered ONLY if peripheral arthritis is present. 3

Spinal Manipulation

• Absolutely contraindicated in patients with spinal fusion or advanced osteoporosis due to risk of fracture, spinal cord injury, and paraplegia. 1

Adjunctive Treatments

Local Corticosteroid Injections

• Intra-articular or periarticular corticosteroid injections may be used for localized peripheral arthritis, sacroiliitis, or enthesitis. 2
• These provide targeted relief without systemic glucocorticoid exposure. 2

Analgesics

• Acetaminophen or opioids may be considered for residual pain when NSAIDs are contraindicated, insufficient, or poorly tolerated. 2, 3

Surgical Interventions

Total Hip Arthroplasty

• Strongly recommend total hip arthroplasty for patients with advanced hip arthritis causing severe pain or mobility limitation. 1
• Surgery should be performed at centers with extensive experience in joint replacement for AS patients. 1

Spinal Osteotomy

• Generally NOT recommended due to 4% perioperative mortality and 5% permanent neurologic sequelae. 1
• May be considered only in highly selected patients with severe kyphosis lacking horizontal vision, performed at specialized centers. 1

Management of Extra-Articular Manifestations

Acute Uveitis

• All episodes of acute iritis must be treated by an ophthalmologist to prevent complications. 1

Inflammatory Bowel Disease

• Manage in collaboration with gastroenterology. 3, 4
• Remember: use monoclonal antibody TNF inhibitors, NOT etanercept. 1

Disease Monitoring

• Monitor disease activity using patient history, clinical parameters (spinal mobility, chest expansion), inflammatory markers (ESR, CRP), and imaging as clinically indicated. 3, 4
• Assess for cardiovascular disease risk and osteoporosis, as AS patients have increased risk. 3, 4

Critical Pitfalls to Avoid

• Do not delay TNF inhibitor therapy in patients with persistently high disease activity despite adequate NSAID and physical therapy trials. 3
• Do not prescribe DMARDs for axial symptoms—they provide no benefit and delay effective treatment. 3, 4
• Do not use systemic corticosteroids for axial disease. 1, 3
• Do not neglect physical therapy—it is as essential as pharmacotherapy. 1, 3
• Do not use etanercept in patients with inflammatory bowel disease. 1