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.

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



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


  • 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 (IBD)

Disease-Modifying Antirheumatic Drugs (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 (SPA)
  • Further studies are needed to prove the efficacy of Methotrexate and other disease-modifying antirheumatic drugs (DMARDs) for the treatment of ankylosing spondylitis (AS)
  • 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

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) 

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

Pamidronic acid (Pamidronate)

  • Treatment option for active ankylosing spondylitis (AS) patients with contraindications to tumor necrosis factor (TNF) inhibitors therapy
  • Further studies are needed ro prove the use of Pamidronate for the management of active ankylosing spondylitis (AS)

Tumor Necrosis Factor (TNF) Inhibitors

  • Eg Adalimumab, Etanercept, Infliximab, Golimumab, Certolizumab pegol
  • Indicated in ankylosing spondylitis (AS) patients wpersistently high disease activity despite non-steroidal anti-inflammatory drugs (NSAIDs) treatment
  • Requirements before initiation of anti-tumor necrosis factor (TNF)F therapy:
    • Confirmed diagnosis of ankylosing spondylitis (AS) based on the modified New York criteria for ankylosing spondylitis (AS)
    • Sustained active disease [a bath ankylosing spondylitis disease activity (BASDAI) of ≥4 units on a 0–10 scale, ≥4 cm on 0–10 cm spinal pain visual analogue scale (VAS) and expert opinion based on clinical findings] of ≥4 weeks
    • Negative for tuberculosis or viral hepatitis
    • Presence of refractory disease
      • Treatment failure with ≥2 non-steroidal anti-inflammatory drugs (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 Assessment in SpondyloArthritis international Society core set, laboratory tests, imaging, and bath ankylosing spondylitis disease activity (BASDAI) is recommended after initiation of treatment
  • Adequate response to tumor necrosis factor (TNF) inhibitors:
    • Bath ankylosing spondylitis disease activity (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 (TNF) inhibitor is recommended when response is no longer seen with initial tumor necrosis factor (TNF) inhibitor

Management of Comorbidities

  • Ag Inflammatory bowel disease (IBD), 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 (AS) patient with recurrent iritis
  • Ankylosing spondylitis (AS) patients with inflammatory bowel disease (IBD) may benefit from tumor necrosis factor (TNF) inhibitor monoclonal antibodies
  • Any change in the course of ankylosing spondylitis (AS) (eg spinal fracture) should prompt further investigation especially imaging studies
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