Initial Management of Ankylosing Spondylitis

Assessment and Diagnosis

Diagnosis of ankylosing spondylitis is based on modified New York criteria, which include radiological evidence of sacroiliitis and clinical criteria such as low back pain/stiffness for >3 months that improves with exercise but not rest, as recommended by the European League Against Rheumatism 3
Disease monitoring should include patient history, clinical parameters (including BASDAI score), laboratory tests (e.g. inflammatory markers), and imaging according to clinical presentation, as suggested by the Annals of the Rheumatic Diseases 4

Patient education and regular exercise are cornerstone treatments and should be initiated immediately upon diagnosis, according to the Annals of the Rheumatic Diseases 4
Individual and group physical therapy should be considered as part of initial management, as recommended by the Annals of the Rheumatic Diseases 4
Group therapy shows better patient global assessment outcomes than individual therapy alone, as found by the Annals of the Rheumatic Diseases 4

NSAIDs are recommended as first-line drug treatment for patients with pain and stiffness, with convincing level Ib evidence that NSAIDs improve spinal pain, peripheral joint pain, and function over short periods (6 weeks), as stated by the Annals of the Rheumatic Diseases 1, 4
For patients with increased gastrointestinal risk, consider either non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor, as recommended by the Annals of the Rheumatic Diseases 1

Analgesics such as paracetamol and opioids might be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated, as suggested by the Annals of the Rheumatic Diseases 1
Corticosteroid injections directed to local sites of musculoskeletal inflammation may be beneficial for peripheral arthritis or enthesitis, as recommended by the Annals of the Rheumatic Diseases 1

Anti-TNF treatment (e.g. infliximab, etanercept) should be given to patients with persistently high disease activity (BASDAI >4) despite at least two NSAIDs for at least 3 months, as recommended by the Annals of the Rheumatic Diseases 3

Overreliance on imaging findings without correlation to clinical symptoms can lead to unnecessary interventions, as warned by the European League Against Rheumatism 5
Failure to incorporate both pharmacological and non-pharmacological approaches limits treatment effectiveness, as stated by the European League Against Rheumatism 5
Systemic corticosteroids should be avoided for axial disease due to lack of evidence and potential side effects, as recommended by the European League Against Rheumatism 2
Not considering anti-TNF therapy in patients with persistently active disease despite adequate NSAID trials, as suggested by the European League Against Rheumatism 2
Inadequate trials of NSAIDs before declaring treatment failure (should try at least two different NSAIDs at maximum tolerated dose for at least 3 months each), as recommended by the Annals of the Rheumatic Diseases 3