Treatment Guideline Chart
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



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


  • Direct injection of glucocorticoids to the local site (eg musculoskeletal inflammation) may be considered in ankylosing spondylitis (AS) patients with stable axial disease and active enthesis or active peripheral arthritis who are unresponsive to non-steroidal anti-inflammatory drugs (NSAIDs) therapy
  • Intravenous/oral corticosteroids should only be considered as short-term therapy (not >2 weeks) in patients with flares during pregnancy, peripheral arthritis, or inflammatory bowel disease

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
Conventional Synthetic DMARDs

  • Eg Methotrexate, Sulfasalazine
  • Therapeutic option for patients unresponsive to NSAIDs, intolerant of tumor necrosis factor (TNF) inhibitors or TNF inhibitors are not available
  • May be considered in patients with peripheral SpA or extra-articular manifestations
    • Treatment with Sulfasalazine may be considered in patients with peripheral SpA
  • Further studies are needed to prove the efficacy of Methotrexate and other DMARDs for the treatment of AS
  • Concomitant use with TNF inhibitors or NSAIDs is not recommended, as it increases the risk for adverse effects
Tunor Necrosis Factor (TNF) Inhibitors
  • Eg Adalimumab, Certolizumab pegol, Etanercept, Golimumab, Infliximab 
  • Indicated in AS patients with persistently high disease activity despite NSAIDs treatment
  • Requirements before initiation of anti-TNF therapy:
    • Confirmed diagnosis of AS based on the modified New York criteria for AS
    • Sustained active disease (a BASDAI of ≥4 units on a 0–10 scale, ASDAS-CRP ≥2.1, ≥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, human immunodeficiency virus (HIV) (in high-risk populations) or viral hepatitis B and C
    • Presence of refractory disease
      • Treatment failure with ≥2 NSAIDs for 4 weeks with predominantly axial SpA
      • 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 VAS after 12 weeks of treatment
  • Switching to another tumor necrosis factor inhibitor is recommended when response is no longer seen for at least 12 weeks with initial tumor necrosis factor inhibitor

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) 

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

Pamidronic acid (Pamidronate)

  • Treatment option for active AS patients with contraindications to TNF inhibitors therapy
  • Further studies are needed ro prove the use of Pamidronate for the management of active AS
Interleukin (IL) Inhibitor
  • Eg Ixekizumab, Secukinumab
  • Human selective inhibitor of IL-17A used in the treatment of moderate-to-severe AS
  • Can be considered in patients if initial TNF inhibitors treatment fails or if with contraindications to TNF inhibitors

Management of Comorbidities

  • Eg inflammatory bowel disease, psoriasis, uveitis should be managed accordingly (Please refer to the respective disease management charts for further information)
  • Infliximab or Adalimumab and topical corticosteroids may be prescribed to AS patient with recurrent iritis
  • AS patients with inflammatory bowel disease may benefit from TNF inhibitor monoclonal antibodies
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