Ankylosing spondylitis (AS) is a chronic inflammatory arthritis that causes pain and stiffness, primarily in the spine. Over time, it can lead to the fusion of spinal vertebrae, resulting in a loss of flexibility, and may also affect other joints and organs like the eyes, heart, and lungs. To manage this complex disease, medical organizations have developed evidence-based treatment guidelines. These guidelines provide a structured framework for doctors and patients, created by reviewing scientific evidence and expert consensus. The primary goals are to control inflammation, alleviate symptoms, and maintain physical function.
Foundational Non-Drug Therapies
The management of ankylosing spondylitis begins with non-pharmacological therapies, which are recommended for all patients. Physical therapy is a central component of this approach, designed to address stiffness and reduced mobility with tailored exercise regimens. The primary objectives are to preserve spinal flexibility, improve posture, and enhance overall physical function.
Specific exercises focus on stretching the muscles of the back and chest, core strengthening exercises to support the spine, and low-impact aerobic activities like swimming. Beyond structured exercise, patient education is a significant part of foundational care. Understanding the nature of AS and its treatment rationale empowers individuals to take an active role in their health. Lifestyle modifications are also addressed, with smoking cessation being a strong recommendation as it can worsen disease activity.
First-Line Pharmacological Treatments
When non-drug therapies are not enough to control symptoms, the first line of medication is Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). These medications are the initial choice for active inflammation because they relieve pain and reduce the underlying inflammation. If a patient does not respond to an initial NSAID, guidelines recommend trying at least one other type for two to four weeks, as individual responses can vary.
For optimal control of inflammation, guidelines favor the continuous use of NSAIDs rather than taking them only as needed for pain. This approach helps maintain a steady level of medication to suppress the inflammatory process. Throughout treatment, physicians monitor for potential side effects affecting the gastrointestinal system, kidneys, or cardiovascular health.
Advanced Pharmacological Treatments
When NSAIDs fail to adequately control disease activity, guidelines recommend escalating to more advanced medications for patients with persistent symptoms. The decision to advance therapy is based on a thorough evaluation of the patient’s condition. The choice between these therapies is tailored to the individual’s disease characteristics and medical history.
Biologic DMARDs
Biologic Disease-Modifying Antirheumatic Drugs (DMARDs) are complex proteins engineered to target specific components of the immune system. Tumor Necrosis Factor (TNF) inhibitors are a primary choice, working by blocking TNF, a protein that promotes inflammation. Another primary option is Interleukin-17 (IL-17) inhibitors, which target the IL-17 inflammatory pathway.
JAK Inhibitors
Janus kinase (JAK) inhibitors offer an oral alternative to the injections or infusions required for most biologics. These small molecule drugs work inside the cell to disrupt signaling pathways that lead to inflammation. They are recommended for patients for whom biologic DMARDs may not be appropriate or have not been effective.
Surgical Interventions
Surgery is considered a treatment option for a small fraction of individuals with ankylosing spondylitis who have developed severe, advanced-stage complications. It is not a standard part of treatment for the majority of patients but is reserved for situations where structural damage has led to significant pain or functional impairment. The guidelines frame surgery as a way to address the consequences of the disease, rather than the underlying inflammation itself.
One of the most common surgical procedures for AS patients is total hip arthroplasty, or hip replacement. This intervention is recommended for individuals who have severe arthritis in their hip joints. Over time, the inflammation of AS can destroy the cartilage in the hips, leading to debilitating pain and a major loss of mobility. A hip replacement can alleviate pain and restore function, dramatically improving the patient’s quality of life.
Spinal surgery is a more complex and less common intervention reserved for patients with severe structural deformities. In some advanced cases of AS, the spine can become fused in a forward-flexed position, making it difficult to stand upright or look straight ahead. A procedure known as a spinal osteotomy may be performed to correct this severe flexion. This involves cutting and realigning the vertebrae to improve posture and function.
Monitoring and Adjusting Treatment
Long-term management of ankylosing spondylitis involves a dynamic and ongoing process of monitoring and adjustment. The “Treat-to-Target” (T2T) strategy is a central concept in modern AS care that is reflected in treatment guidelines. This approach involves a collaborative effort between the patient and their rheumatologist to define a specific treatment goal, such as achieving remission or maintaining a state of low disease activity.
To track progress toward this goal, clinicians use a combination of monitoring tools. Patient-reported outcomes are a key component, utilizing standardized questionnaires like the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). This scale allows patients to score their own symptoms, such as pain, stiffness, and fatigue, providing a personal measure of how the disease is affecting them.
Physicians also conduct their own clinical assessments, evaluating joint mobility, tenderness, and swelling. This physical examination provides objective data that complements the patient’s reported experience. Blood tests that measure inflammatory markers, such as C-reactive protein (CRP), are used to gauge the level of inflammation in the body.
Imaging studies also play a role in monitoring the disease over time. X-rays can reveal long-term structural changes and damage to the spine and other joints, while Magnetic Resonance Imaging (MRI) is particularly useful for detecting active inflammation in the sacroiliac joints and spine. This comprehensive monitoring allows the healthcare team to systematically adjust treatments, ensuring the therapeutic plan remains optimized to control the disease and meet the established targets.