What steroid pulse regimen is recommended for an adult with ankylosing spondylitis experiencing an acute inflammatory flare and no contraindications to high‑dose glucocorticoids?

Steroid Pulse Therapy for Ankylosing Spondylitis Flare

Systemic glucocorticoid pulse therapy is strongly recommended against for routine use in ankylosing spondylitis flares, but short-term high-dose prednisolone (50 mg daily) with rapid tapering may be considered only in very specific circumstances: polyarticular peripheral arthritis flare, pregnancy-related flares, or concurrent inflammatory bowel disease flares. 1

Why Systemic Steroids Are Not Recommended

The American College of Rheumatology/Spondylitis Association of America guidelines provide a strong recommendation against systemic glucocorticoids for active AS based on very low-quality evidence. 1 The evidence base is limited to:

• One 2-week randomized placebo-controlled trial showing prednisolone 50 mg daily was superior to placebo in only 5 of 10 outcomes 1
• Three case series with serious risk of bias showing modest improvements over 4-6 months 1
• The overall quality of evidence was rated as very low 1

When Short-Term Systemic Steroids May Be Considered

If you decide to use systemic glucocorticoids despite the strong recommendation against them, limit use to these three specific scenarios only: 1

• Polyarticular flare of peripheral arthritis (multiple joints involved simultaneously) 1
• Flares during pregnancy (when other options are limited) 1
• Concomitant inflammatory bowel disease flares (when treating both conditions) 1

Pulse Therapy Regimen (If Used Despite Recommendations)

Based on research evidence showing short-term efficacy, the following regimens have been studied: 2, 3, 4

Intravenous methylprednisolone pulse:

• 500-1000 mg IV as 1-3 infusions 2
• Intervals between infusions: 1-8 days 2
• Total cumulative dose: 500-3000 mg 2
• Alternative: Dexamethasone 120-360 mg total dose (comparable efficacy) 2

Oral prednisolone (from the single RCT):

• 50 mg daily for up to 2 weeks with rapid taper 1

Expected outcomes from pulse therapy:

• Immediate positive response in most patients 2
• 48% achieve ≥50% reduction in BASDAI 2
• 76% achieve ASAS20 response 2
• 45% achieve ASAS40 response at 2 weeks 3
• Critical limitation: Effect persists only 3 months in 41% of patients, with significant effect lasting 3 months in only 9% 2

Preferred Alternative: Local Glucocorticoid Injections

For isolated active sacroiliitis despite NSAIDs, locally administered parenteral glucocorticoids are conditionally recommended over systemic therapy. 1, 5

• Sacroiliac joint injections show pain improvement for up to 9 months 1
• Intra-articular injections for peripheral arthritis achieve sustained response in 51.5-90% of joints at 6 months 4
• Avoid peri-tendon injections around Achilles, patellar, and quadriceps tendons due to rupture risk 1
• Consider injections at greater trochanter, pelvic rim, and plantar fascia attachment 1

Safety Profile of Pulse Therapy

When pulse therapy was studied: 2, 3

• Side effects occurred in 56% of patients 2
• Severe side effects in 17% of cases 2
• No deaths or major adverse events reported 4
• No serious adverse events in the 12-week prospective study 3

What to Do Instead of Systemic Steroids

The evidence-based treatment algorithm for AS flares prioritizes: 6, 5

1. NSAIDs as first-line with at least 1-month trial before declaring failure 5
2. TNF inhibitors for active disease despite NSAIDs (strong recommendation) 6, 5
3. IL-17 inhibitors (secukinumab or ixekizumab) as alternatives or after TNF inhibitor failure 6, 5
4. Physical therapy (strongly recommended for all patients) 1, 5

Critical Pitfalls to Avoid

• Do not use systemic glucocorticoids for axial disease flares (the strong recommendation against this is based on lack of efficacy and potential harm) 1, 5
• Do not use long-term systemic glucocorticoids (no evidence supports this approach) 1
• Do not inject around Achilles, patellar, or quadriceps tendons (high rupture risk) 1
• Do not add sulfasalazine or methotrexate for axial disease (ineffective for axial symptoms) 6