• 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

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

• 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

• 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