What are the American College of Rheumatology treatment guidelines for active ankylosing spondylitis (AS) despite treatment with NSAIDs?

Updated: Feb 02, 2021
  • Author: Lawrence H Brent, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

In adults with active AS despite treatment with NSAIDs :

  • Conditionally recommend treatment with sulfasalazine, methotrexate, or tofacitinib over no treatment with those medications; sulfasalazine or methotrexate should be considered only in patients with prominent peripheral arthritis or when a tumor necrosis factor inhibitor (TNFi) is not available. 
  • Conditionally recommend treatment with a TNFi over treatment with tofacitinib
  • Strongly recommend treatment with a TNFi over no treatment with TNFi
  • No recommendation for any particular TNFi as the preferred choice
  • Strongly recommend treatment with secukinumab or ixekizumab over no treatment with those agents;
  • Conditionally recommend treatment with a TNFi over treatment with secukinumab or ixekizumab 
  • Conditionally recommend treatment with secukinumab or ixekizumab over treatment with tofacitinib
  • In patients who have contraindications to TNFis, conditionally recommend treatment with secukinumab or ixekizumab over treatment with sulfasalazine, methotrexate, or tofacitinib 
  • In patients with primary nonresponse to TNFi therapy, conditionally recommend treatment with secukinumab or ixekizumab over treatment with a different TNFi
  • In patients with secondary nonresponse to TNFi therapy, conditionally recommend treatment with a different TNFi over treatment with a non-TNFi biologic
  • In patients whose AS does not respond to treatment with the first TNFi used, strongly recommend against switching to treatment with a biosimilar of the first TNFi
  •  In patients whose AS does not respond to treatment with the first TNFi used, conditionally recommend against the addition of sulfasalazine or methotrexate in favor of treatment with a new biologic
  • In adults with AS and isolated active sacroiliitis despite treatment with NSAIDs, conditionally recommend treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids
  • In adults with AS with stable axial disease and active enthesitis despite treatment with NSAIDs, conditionally recommend using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids; however, peri-tendon injections of Achilles, patellar, and quadriceps tendons should be avoided
  • In adults with AS with stable axial disease and active peripheral arthritis despite treatment with NSAIDs, conditionally recommend using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids
  • Strongly recommend treatment with physical therapy over no treatment with physical therapy
  • Conditionally recommend active physical therapy interventions (supervised exercise) over passive physical therapy interventions (massage, ultrasound, heat)
  • Conditionally recommend land-based physical therapy interventions over aquatic therapy interventions

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