ankylosing%20spondylitis
ANKYLOSING SPONDYLITIS
Spondyloarthritis refers to a group of inflammatory diseases characterized by spinal & joint oligoarthritis, enthesitis, and sometimes mucocutaneous, ocular and/or cardiac manifestations.
Ankylosing spondylitis is a prototype of spondyloarthritis, particularly of the axial form.
Diagnosis of ankylosing spondylitis is definite if any of the radiological criterion (grade≥2 bilateral sacroiliitis or grade ≥3 unilateral sacroiliitis) is associated with at least one of the clinical criterion (low back pain & stiffness for >3 months that improves with exercise but not relieved by rest, limitation of motion of the lumbar spine in the sagittal and frontal planes, limitation of chest expansion relative to normal values correlated for age and gender.

Ankylosing%20spondylitis Treatment

Principles of Therapy

  • Maximize long-term quality of life by:
    • Controlling occurrence and severity of symptoms
    • Reduce functional limitations
    • Maintain flexibility and posture of the vertebral column
    • Preventing continuous structural damage and disease complications
    • Improvement in social interaction/quality of life
    • Normalization of everyday activities
  • Disease management involves the combination of non-pharmacological and pharmacological strategies
  • Treatment approach should be based on the disease activity, as well as presence of comorbidities, structural changes, functional impairment, extra-articular manifestations, and side effects of treatments

Pharmacotherapy

Analgesics

  • Eg Paracetamol, 0pioids
  • May be prescribed to patients with residual pain after treatment failure with other drugs

Corticosteroids

  • Direct injection to the local site may be considered in ankylosing spondylitis (AS) patients with stable axial disease and active enthesis or peripheral arthritis who are unresponsive to non-steroidal anti-inflammatory drugs (NSAIDs) therapy
  • Intravenous/per orem (IV/PO) corticosteroids should only be considered as short-term therapy in patients with flares during pregnancy, peripheral arthritis, or inflammatory bowel disease

Disease-Modifying Antirheumatic Drugs (DMARDs)
Conventional Synthetic DMARDs

  • Eg Methotrexate, Sulfasalazine
  • Therapeutic option for patients unresponsive to non-steroidal anti-inflammatory drugs (NSAIDs) and intolerant of tumor necrosis factor (TNF) inhibitors
  • Treatment with Sulfasalazine may be considered in patients with peripheral spondyloarthritis
  • Further studies are needed to prove the efficacy of Methotrexate and other disease-modifying antirheumatic drugs (DMARDs) for the treatment of ankylosing spondylitis
  • Concomitant use with tumor necrosis factor (TNF) inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs) is not recommended, as it increases the risk for adverse effects
Tunor Necrosis Factor (TNF) Inhibitors
  • Eg Methotrexate, Sulfasalazine
  • Indicated in ankylosing spondylitis patients with persistently high disease activity despite non-steroidal anti-inflammatory drugs (NSAIDs) treatment
  • Requirements before initiation of anti-tumor necrosis factor therapy:
    • Confirmed diagnosis of ankylosing spondylitis based on the modified New York criteria for ankylosing spondylitis
    • Sustained active disease [a BASDAI of ≥4 units on a 0–10 scale, ≥4 cm on 0–10 cm spinal pain visual analogue scale and expert opinion based on clinical findings] of ≥4 weeks
    • Negative for tuberculosis or viral hepatitis
    • Presence of refractory disease
      • Treatment failure with ≥2 NSAIDs for 4 weeks with predominantly axial spondyloarthritis
      • Failure of intra-articular steroids
      • Treatment failure with Sulfasalazine for 4 months in patients with predominantly peripheral arthritis
    • Using precautions and observing contraindications when using biological treatments
  • Monitoring of ASAS core set, laboratory tests, imaging, and BASDAI is recommended after initiation of treatment
  • Adequate response to tumor necrosis factor inhibitors:
    • BASDAI reduced to 50% or ≥2 units of pretreatment value
    • ≥2 cm spinal pain visual analogue scale (VAS) after 12 weeks of treatment
  • Switching to another tumor necrosis factor inhibitor is recommended when response is no longer seen with initial tumor necrosis factor inhibitor

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) 

  • First-line agents for ankylosing spondylitis patients with pain and stiffness
  • Continuous long-term therapy is preferred for ankylosing spondylitis patients with active and symptomatic ankylosing spondylitis and on-demand therapy for stable ankylosing spondylitis
  • On-demand therapy is preferred for patients with stable ankylosing spondylitis
  • Studies show that continuous use of NSAIDs have the potential to reduce the radiographic progression of ankylosing spondylitis

Pamidronic acid (Pamidronate)

  • Treatment option for active ankylosing spondylitis patients with contraindications to tumor necrosis factor inhibitors therapy
  • Further studies are needed ro prove the use of Pamidronate for the management of active ankylosing spondylitis
Secukinumab
  • Human selective inhibitor of IL-17A used in the treatment of moderate-to-severe ankylosing spondylitis
  • Can be considered in patients if initial TNF inhibitors treatment fails

Management of Comorbidities

  • Eg inflammatory bowel disease, psoriasis, uveitis should be managed accordingly. Please refer to the respective disease management charts in MIMS Specialty Editions
  • Infliximab or Adalimumab and topical corticosteroids may be prescribed to ankylosing spondylitis patient with recurrent iritis
  • Ankylosing spondylitis patients with inflammatory bowel disease may benefit from tumor necrosis factor inhibitor monoclonal antibodies
  • Any change in the course of ankylosing spondylitis (eg spinal fracture) should prompt further investigation especially imaging studies
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Rheumatology digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
05 Feb 2021

Primary immunodeficiency disease (PIDD) and allergies are two groups of conditions related to the immune system. However, they are uniquely different in terms of symptoms and treatment.

Roshini Claire Anthony, 24 Feb 2021

Switching from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF) did not result in worsening renal function or bone mineral density (BMD) in Asian patients with chronic hepatitis B virus (HBV) infection, according to a small real-world prospective study.

Roshini Claire Anthony, 6 days ago

Critical or severe COVID-19 disease could raise the risk of negative perinatal outcomes in pregnant women, according to an observational study from the US.

Stephen Padilla, 22 Feb 2021
Treatment with intravenous (IV) dexamethasone for 10 days significantly reduces duration of mechanical ventilation at 28 days and 60-day mortality in patients with established moderate-to-severe acute respiratory disease syndrome (ARDS) compared with no dexamethasone, results of the DEXA-ARDS trial have shown.