Experts at the National Institutes of Health conducted systematic reviews of the literature to address 57 clinical questions related to the treatment of patients with ankylosing spondylitis (AS) or nonradiographic axial spondyloarthritis (SpA).
For patients with active AS, the authors strongly recommend the use of nonsteroidal anti-inflammatory drugs (NSAIDs) but do not single out any particular NSAID as the preferred choice. For patients with active AS despite NSAID therapy, the authors strongly recommend treatment with a tumor necrosis factor (TNF) inhibitor over no treatment with a TNF inhibitor. They conditionally recommend against treatment with slow-acting antirheumatic drugs (SAARDs) following NSAID therapy, based on evidence of small or no clinical effects. In adults with active AS despite treatment with NSAIDs who have contraindications to a TNF inhibitor, the authors conditionally recommend treatment with a SAARD over treatment with a non-TNF inhibitor biologic agent.
The authors strongly recommend against treatment with systemic glucocorticoids in patients with active AS, but conditionally recommend the use of locally administered parenteral glucocorticoids over no treatment with local glucocorticoids in patients with active AS and isolated active sacroiliitis despite treatment with NSAIDs.
The authors also strongly recommend treatment with physical therapy over no treatment with physical therapy in patients with active AS.
The authors conditionally recommended TNF inhibitors for patients who have active nonradiographic axial SpA despite treatment with NSAIDs. For patients with nonradiographic SpA, other recommendations were the same as for patients with AS.
“These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA,” the authors write. “Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.”