Treating Ankylosing Spondylitis in 2010

Stephen Paget, MD

Disclosures

August 30, 2010

Question:

In 2010, how should ankylosing spondylitis be treated?

Response from Stephen Paget, MD
Professor of Medicine, Weill Cornell Medical College, New York, NY; Physician-in-Chief, Center for Rheumatology, Hospital for Special Surgery, New York, NY

In 2010, How Should Ankylosing Spondylitis Be Treated?

In any systemic inflammatory joint and enthesopathic disorder like ankylosing spondylitis (AS), there are four main therapeutic goals: control pain and inflammation, avoid joint and tissue damage, optimize function, and prevent the development of extra-articular manifestations like uveitis. While excellent treatment modalities like tumor necrosis factor (TNF) inhibitors often help to achieve all of these desired outcomes, patients vary in the extent of such responses and initial disease control may eventually give way to a disease flare as the illness takes a "detour" around tumor necrosis factor alpha.

Treatment of AS in the Old Days

When ankylosing spondylitis had not yet been conceptualized as a separate entity from rheumatoid arthritis (eg, rheumatoid spondylitis), the illnesses seemed clinically different because patients with AS responded better to treatment with powerful nonsteroidal anti-inflammatory drugs (NSAIDs) like indomethacin and phenylbutazone than to high doses of acetylsalicylic acid (eg, can you believe four 325 mg tablets four times daily?). We still employ indomethacin as well as other newer NSAIDs for the treatment of AS, and some investigators today even feel that drugs like celecoxib may be disease-modifying, as derived from the results of retrospective studies. Probably prompted by such data, European League Against Rheumatism (EULAR) guidelines today actually recommend initially using NSAIDs before TNF inhibitors in AS. How much of that decision was guided by cost issues is unknown to me. However, in my mind, while NSAIDs are helpful in controlling inflammation and pain, they cannot be counted on to alter the natural history of any systemic inflammatory disorder. If one is to "strike while the iron's hot" during the therapeutic window of opportunity in a disorder like AS, it cannot be left to NSAIDs alone to do this.

Methotrexate and Sulfasalazine Are Ineffective in Controlling AS Spine/Sacroiliac Joint Disease

While methotrexate and sulfasalazine are effective in controlling peripheral joint inflammation in the spondyloarthropathies like ankylosing spondylitis, psoriatic arthritis, colitic arthropathies, and reactive arthritis, they appear to be ineffective in controlling inflammation and damage in the spine/sacroiliac (SI) joints. Thus, when such axial/SI disease exists, anti-TNFs are needed.

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