Ankylosing Spondylitis When NSAIDs Have Failed to Control Back Pain and Spinal Stiffness
For patients with ankylosing spondylitis whose back pain and spinal stiffness remain uncontrolled after an adequate first-line trial, a structured next-line approach is indicated. This protocol defines the conditions for escalation and the therapeutic direction to take.
Previous line — failure condition
First-line management comprised NSAIDs at the maximum tolerated dose used continuously as needed, together with education about axial spondyloarthritis, regular exercise, physiotherapy, and smoking cessation. Escalation to this protocol is triggered by failure to control back pain and spinal stiffness at 2–4 weeks.
Next-line approach (partial overview)
For patients with persistently high disease activity despite the above, current practice supports escalation to a biologic therapy targeting a specific inflammatory pathway. A second class of targeted agent may also be considered in appropriate cases. The complete selection criteria, sequencing, and monitoring steps are in the full protocol.
Target: clinically important improvement in disease activity by 12 weeks
References
DOI: 10.1136/ard-2022-223296
- TNFi, IL-17i or JAKi should be considered in patients with persistently high disease activity despite conventional treatments (figure 1); current practice is to start a TNFi or IL-17i.
- This means non-pharmacological treatment and the use of at least two NSAIDs, in the maximum dose used in axSpA, over a total period of 4 weeks.
- Figure 3 summarises the criteria for continuation, namely that after at least 12 weeks of treatment, the disease activity has substantially decreased, as assessed by the ASDAS clinical important improvement, that is, improvement in ASDAS ≥1.1, together with the positive opinion from the rheumatologist to continue.
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