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
- 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