Ankylosing spondylitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]


Pharmacologic medical therapies for ankylosing spondylitis(AS) include Nonsteroidal anti-inflammatory drugs (NSAIDs), tumor necrosis factor (TNF) blocker, and interleukin 17 (IL-17) inhibitors.Ankylosing spondylitis (AS) is a chronic inflammatory disease which is manifested by back pain and gradually to spinal stiffness.While treating the AS patients the primary goal is to maximize long-term health-related quality of life.

Medical Therapy

Nonsteroidal antiinflammatory drugs(NSAIDs)[4][5][6][7][8][9]


Tumor necrosis factor alpha antagonists(TNF-alpha)[18][19][20][21][22]

  • Infliximabetanerceptadalimumab, certolizumab, and golimumab are the available tumor necrosis factor alpha inhibitors(TNF-alpha) to treat AS.
  • In AS there is no much of a use in adding immunomodulatory drug, such as methotrexate (MTX) as the evidence shows no additional benefit but may increase the cost and the risk of adverse effects.[23][24]
  • Treating patients in AS with tumor necrosis factor alpha inhibitors(TNF-alpha) shows significant improvements in disease progress and function such as at least 40 percent improvement from baseline were seen.[25]
  • Adalimumabetanercept, and infliximab have the same efficacy and potency in treating the AS patients.[26]
  • Patients who are getting treated with tumor necrosis factor alpha inhibitors shows approximately 80% good response and at least 50% improvement from the baseline of the disease.[27]
  • Response to TNF antagonists: The following parameters are sighs of a good response to TNF antagonists[28][29]
    • Age, especially young patients.
    • Elevated C-reactive protein (CRP).
    • The best predictor is, Shorter disease duration.
  • Treating with TNF alpha inhibitors in patients with AS shows beneficial effect in improving bone density.[30][31][32]
Side Effects[33]

Adult Dosage

  • Preferred regimen (1): Infliximab 5 mg/kg at 0, 2, and 6 weeks, followed by 5 mg/kg every 6 weeks thereafter.
  • Preferred regimen (2): Etanercept once-weekly dosing: 50 mg once weekly; maximum dose (rheumatoid arthritis): 50 mg/week.
  • Preferred regimen (3): Adalimumab IV: 2 mg/kg at weeks 0, 4, and then every 8 weeks thereafter.
  • Preferred regimen (4): Certolizumab Initial: 400 mg, repeat dose 2 and 4 weeks after initial dose; Maintenance: 200 mg every 2 weeks or 400 mg every 4 weeks.
Disease-modifying antirheumatic drugs(DMARDs)
  • The use of DMARDs regarded as useful but is limited in AS patients with sulfasalazine.
    • Preferred regimen (1): Oral: Initial: 500 mg once daily; may increase up to 2 to 3 g/day in divided doses.

Other DMARDs

  • Pharmacologic medical therapies for Ankylosing spondylitis (AS) include Glucocorticoids but using them for long term basis for patients is not suggested, although high doses of prednisolone may have shown some benefit for very short-term therapy.[34]
Monoclonal antibody[37][38]
  • In the United States Secukinumab has been approved for use in patients with AS.[39]
  • Secukinumab, is an anti-interleukin (IL)-17A monoclonal antibody.[40]
  • IL-17A a proinflammatory cytokine which plays important role in the pathogenesis of AS.[41]
    • Preferred regimen (1): Secukinumab:150 mg administered subcutaneously weekly for four weeks, then every four weeks thereafter.
    • Preferred regimen (2): Ustekinumab: IV: Infuse over at least 1 hour; use of IV set with an in-line, low-protein binding filter (0.2 micrometer) required.
    • Preferred regimen (3): Pamidronate:30 mg/10 mL (10 mL); 90 mg/10 mL (10 mL).[42] 
    • Preferred regimen (4): Rituximab  IV: 1,000 mg on days 1 and 15.[43]
  • Curcuma longa (turmeric) has a very long history of extensive use in Ayurvedic medicine as a treatment for inflammatory conditions in India.[46]
  • Turmeric contains 3 active components called curcuminoids[47]
    • Curcumin(diferuloylmethane)
    • Demethoxycurcumin
    • Bisdemethoxycurcumin
  • Turmeric when administered orally in the diet improves both the wasting and histopathological signs of inflammation.
  • Curcumin also suppress the expression of inflammatory cytokines such as TNF-α.
  • Curcumin when combined with IL-10, curcumin inhibited NF-κB quite effectively.[48]


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