What is the recommended treatment for ankylosing spondylitis?

Treatment of Ankylosing Spondylitis

Start with continuous daily NSAIDs at full therapeutic doses combined with physical therapy as first-line treatment for active ankylosing spondylitis, then escalate to TNF inhibitors if disease remains active despite adequate NSAID trial. 1, 2

Initial Management for Active Disease

First-Line Pharmacotherapy

• Begin any NSAID at full therapeutic dose continuously rather than on-demand during active disease periods, as no specific NSAID demonstrates superiority over others 1, 2
• Trial 2-3 different NSAIDs at optimal doses for at least 3 months total before declaring NSAID failure 2, 3
• Consider COX-2 selective NSAIDs for patients with gastrointestinal risk factors requiring long-term continuous use 2
• Expect 75% of patients to show good or very good response within 48 hours if inflammatory rather than mechanical pain 2

Physical Therapy (Mandatory Component)

• Strongly recommend physical therapy simultaneously with NSAID initiation for all patients with ankylosing spondylitis 1, 4, 2
• Prioritize active supervised exercise programs over passive modalities (massage, ultrasound, heat) 1, 4
• Use land-based exercises as primary approach over aquatic therapy 1, 4
• Prescribe unsupervised home back exercises for ongoing self-management between supervised sessions 4

Escalation to Biologic Therapy

When to Initiate TNF Inhibitors

• Strongly recommend TNF inhibitor therapy when disease remains active despite adequate NSAID trial (2-3 NSAIDs over 3 months) and physical therapy 1, 2
• Ensure active disease defined by sustained BASDAI >4 on 0-10 scale for at least 4 weeks 3
• Screen for tuberculosis before initiating TNF inhibitor therapy 3, 5

TNF Inhibitor Selection

• No particular TNF inhibitor is preferred as first choice for uncomplicated ankylosing spondylitis 1
• For patients with concomitant inflammatory bowel disease or recurrent uveitis, use TNF inhibitor monoclonal antibodies (infliximab, adalimumab, golimumab, certolizumab) rather than etanercept 1, 4, 2
• For patients with heart failure or demyelinating disease as contraindications to TNF inhibitors, use secukinumab or ixekizumab instead 1

Monitoring TNF Inhibitor Response

• Assess response after 6-12 weeks of TNF inhibitor therapy 3, 5
• Define response as improvement of at least 50% or 2 units (on 0-10 scale) of BASDAI 3
• Discontinue TNF inhibitor in non-responders after 6-12 weeks 3

Management of TNF Inhibitor Failure

Primary Non-Response (Never Responded)

• Conditionally recommend switching to secukinumab or ixekizumab over trying a different TNF inhibitor 1, 4
• Alternatively, consider switching to a different TNF inhibitor if IL-17 inhibitors are contraindicated 1

Secondary Non-Response (Lost Response Over Time)

• Conditionally recommend switching to a different TNF inhibitor over switching to non-TNFi biologic 1, 4
• Do not add sulfasalazine or methotrexate to failing TNF inhibitor; switch to new biologic instead 1

IL-17 Inhibitor Use

• Strongly recommend secukinumab or ixekizumab over no treatment when NSAIDs fail 1
• Conditionally recommend TNF inhibitors over IL-17 inhibitors as first biologic choice 1
• Do not use IL-17 inhibitors in patients with inflammatory bowel disease or recurrent uveitis, as TNF inhibitor monoclonal antibodies are superior 1

Treatments to Avoid

Strongly Contraindicated

• Strongly recommend against systemic glucocorticoids for axial disease 1, 4, 6, 2
• Strongly recommend against switching to biosimilar of the same TNF inhibitor during treatment 1
• Strongly recommend against spinal manipulation in patients with advanced spinal osteoporosis or spinal fusion 4, 2

Not Recommended for Axial Disease

• Do not use conventional synthetic DMARDs (sulfasalazine, methotrexate) as monotherapy for purely axial disease 1, 2
• Do not add low-dose methotrexate to TNF inhibitor therapy as standard approach 1
• Sulfasalazine may be considered only for patients with prominent peripheral arthritis 1

Limited Role Interventions

• Conditionally recommend local glucocorticoid injections only for isolated active sacroiliitis, active enthesitis with stable axial disease, or active peripheral arthritis with stable axial disease 1, 4
• Avoid peri-tendon injections of Achilles, patellar, and quadriceps tendons 1

Management of Stable Disease

Medication Adjustments

• Switch to on-demand NSAID dosing rather than continuous daily dosing once disease is stable 1
• Conditionally recommend against discontinuing biologics due to high likelihood of symptom recurrence 1
• Conditionally recommend against tapering biologic dose as standard approach 1
• If tapering is attempted, counsel patients regarding potential for increased disease activity 1

Combination Therapy Simplification

• Continue TNF inhibitor alone rather than continuing both TNF inhibitor and NSAIDs 1
• Continue TNF inhibitor alone rather than continuing both TNF inhibitor and conventional synthetic DMARD 1

Disease Monitoring

Clinical Assessment

• Conditionally recommend regular-interval use of validated ankylosing spondylitis disease activity measures 1
• Monitor BASDAI and ASAS core set for clinical practice after treatment initiation 3
• Target clinical remission/inactive disease as primary goal, with low/minimal disease activity as alternative when remission unachievable 4

Imaging

• Do not obtain repeat spine radiographs at scheduled intervals (e.g., every 2 years) as standard approach in stable disease 1
• Consider MRI when degree of active inflammation is uncertain and findings would change management 1
• Do not use MRI to seek subclinical inflammation in patients with stable disease activity 1

Special Considerations

Tofacitinib (JAK Inhibitor)

• Conditionally recommend TNF inhibitors over tofacitinib when NSAIDs fail 1
• Consider tofacitinib as potential second-line option only for patients with contraindications to TNF inhibitors other than infections 1
• Conditionally recommend secukinumab or ixekizumab over tofacitinib 1

Surgical Intervention

• Strongly recommend total hip arthroplasty for patients with advanced hip arthritis 4