Ankylosing Spondylitis Management

Introduction

Ankylosing spondylitis (AS) is a chronic inflammatory disease that requires a comprehensive management approach, including pharmacological treatment, physical therapy, and surgical interventions, as recommended by the European League Against Rheumatism and the American College of Rheumatology 1, 2, 3

75% of patients with AS show a good response to NSAIDs within 48 hours, compared to only 15% with mechanical back pain, according to the European League Against Rheumatism 4, 3, 5, 6, 2
COX-2 selective NSAIDs may be preferred for long-term treatment due to fewer gastric side effects, as recommended by the European League Against Rheumatism 4
TNF inhibitors, including adalimumab, infliximab, golimumab, and certolizumab, are strongly recommended for patients with active AS who have inadequate response to NSAIDs, with 50% improvement in about half of treated patients, as reported by the American College of Rheumatology 3, 4, 5, 7, 2
IL-17 inhibitors, such as secukinumab, are an alternative for patients who fail TNF inhibitors, although TNF inhibitors are conditionally recommended as first-line biologic therapy, according to the American College of Rheumatology 8, 5, 2

Avoid NSAIDs in patients with low creatinine clearance, gastropathy, cardiovascular disease, or congestive heart failure, as advised by the American Geriatrics Society and the American College of Physicians 9, 10
Avoid NSAIDs in patients with severe or progressive neurological deficits, suspected cauda equina syndrome, fever or signs of infection, history of cancer or unexplained weight loss, or recent trauma, as recommended by the American College of Physicians 10

There is typically a 5-7 year delay between first symptoms and diagnosis of AS, according to the European League Against Rheumatism 4
Full doses of NSAIDs are needed for anti-inflammatory effect in inflammatory back pain, as recommended by the European League Against Rheumatism 4
Opioids should be avoided for chronic back pain management, as advised by the American College of Physicians 11
Do not routinely obtain imaging for nonspecific low back pain, as recommended by the American College of Physicians 10

Physical therapy is strongly recommended alongside pharmacological treatment, helping to reduce stiffness and prevent spinal ankylosis, and improving physical function and quality of life, as noted by the American College of Rheumatology 3
A comprehensive rehabilitation program incorporating cognitive therapy can be as effective as lumbar fusion for patients with chronic low-back pain due to degenerative disc disease, according to the American College of Rheumatology 12

Regular assessment of disease activity using BASDAI or ASDAS is essential for monitoring treatment response, as recommended by the Assessment of SpondyloArthritis international Society (ASAS) and the American College of Rheumatology 13, 7, 2
Monitoring inflammatory markers, such as ESR and CRP, can help track disease activity, although they may not always be elevated, as noted by the American College of Rheumatology 13, 2
Radiographic follow-up is not necessary more frequently than every 2 years unless significant clinical changes occur, as recommended by the American College of Radiology and the Annals of the Rheumatic Diseases 4, 2, 14, 3, 15

Total Hip Arthroplasty is strongly recommended for patients with advanced hip arthritis, providing significant improvements in pain, functioning, and hip range of motion, as reported by the American College of Radiology and the American College of Rheumatology 3, 6, 14
Spinal osteotomy is conditionally recommended against for most patients with severe kyphosis due to high risks, but may be considered in highly selected patients with severe kyphosis and lack of horizontal vision, as noted by the American College of Radiology and the American College of Rheumatology 3, 14, 15
Surgical intervention is indicated only after failure of conservative management for at least 6 weeks, according to the Journal of the American College of Radiology and the American College of Rheumatology 15, 3

Ensure calcium and vitamin D supplementation, and consider DXA scan of both spine and hips to monitor osteoporosis risk, as recommended by the National Osteoporosis Foundation and the American College of Rheumatology 2
Avoidance of spinal manipulation with high-velocity thrusts is strongly recommended against in patients with spinal fusion or advanced spinal osteoporosis, as noted by the American College of Rheumatology 3
Evaluate fall risk and provide counseling, and consider comorbidities that may affect treatment choices, as recommended by the American Geriatrics Society and the American College of Rheumatology 2