19th January 2024

Management 

All patients with suspected AS should be referred to a rheumatologist for confirmation of diagnosis and initiation of management. The main outcomes of treatment are prevention of disease progression and control of symptoms to maintain a good quality of life for patients. The management plans should be tailored to each individual patient and take into consideration the patient’s disease activity level and degree of functional impairment. A combination of non-pharmacological and pharmacological therapies is recommended.

Non-pharmacological management

All patients should be provided with specific information regarding their disease, prognosis, likely symptoms, potential extra-articular features, and management options. Physiotherapy is essential for patients to optimise their posture, flexibility and motility and can include stretching and strengthening, spinal extension and deep-breathing exercises. Hydrotherapy can also be beneficial in pain management. Patients with AS are more prone to develop cardiovascular disease; therefore, should be routinely assessed for modifiable risk factors. Smoking has been shown to be a key predictor of spinal radiological disease progression; therefore, smoking cessation advice must be offered to patients.

Pharmacological management

• Non-steroidal anti-inflammatory drugs (NSAIDS): NSAIDs are first-line treatment for patients with pain and stiffness in active AS. The lowest effective dose should be used in conjunction with a proton pump inhibitor to minimise the risk of side effects. If NSAIDs are contraindicated, paracetamol and/or codeine can be trialled. If NSAIDs are taken at the maximum tolerated dose for 2-4 weeks and fail to provide adequate control of symptoms, NICE guidelines recommend switching to another NSAID or seeking specialist advice.
• Corticosteroid injections: Steroid injections may be offered to patients with localised inflammation, e.g. peripheral enthesitis.
• Conventional disease-modifying anti-rheumatic drugs (DMARDs): DMARDS such as Sulfasalazine and Methotrexate can be used in the presence of peripheral joint involvement but have not been shown to be effective in treating axial disease
• Biological disease-modifying anti-rheumatic drugs (DMARDs): The European League against Rheumatism (EULAR) recommends the use of anti-tumour necrosis factor (Anti-TNF) therapy for patients with persistently high disease activity, despite the optimal use of conventional therapy such as physiotherapy and NSAIDs. It can also be considered in patients with severe disease who cannot tolerate NSAIDs. Patients do not need to have received a trial of DMARDs before progressing to anti-TNF therapy. Examples of anti-TNF drugs which can be used are Adalimumab, Certolizumab pegol, Etanercept, Golimumab and Infliximab. NSAIDs should be taken in conjunction with anti-TNF inhibitors upon initiation of treatment. Treatment should be assessed after 12 weeks of initiation and only be continued if there is clear evidence of response. In patients who do not receive an adequate response to an anti-TNF medication, NICE recommends switching to another anti-TNF drug. Potential complications of anti-TNF therapy include increased risk of serious infections, malignancy such as lymphoma, worsening of heart failure and increased incidence of demyelinating disease. A baseline chest x-ray and hepatitis B and tuberculosis status should be checked before commencing treatment.