This protocol covers first-line management of ankylosing spondylitis in patients who present with peripheral arthritis. Peripheral joint involvement is a recognised manifestation that shapes both the treatment approach and the criteria used to judge whether initial therapy has succeeded.
The patient has ankylosing spondylitis with peripheral arthritis. Purely axial disease and predominantly peripheral disease are managed differently: sulfasalazine, for example, may be considered specifically when peripheral arthritis is present — a distinction that does not apply to axial-only disease.
For patients with predominantly peripheral manifestations, the criteria that define failure of this first-line protocol include specific pharmacological and procedural steps before escalation to a subsequent line.
Anti-inflammatory drug therapy is the initial pharmacological foundation, combined with a structured non-pharmacological programme. The complete regimen — including the preferred use strategy for the anti-inflammatory agent, additional options relevant to peripheral disease, and the full scope of non-pharmacological interventions — is detailed in the protocol.
Patients with purely axial disease should normally not be treated with csDMARDs; sulfasalazine may be considered in patients with peripheral arthritis.
In patients with predominantly peripheral manifestations, following recommendations 7 and 8, failure to treatment includes one glucocorticoid injection, if appropriate, and the use of sulfasalazine.
Patients suffering from pain and stiffness should use an NSAID as first-line drug treatment up to the maximum dose, taking risks and benefits into account.
For patients who respond well to NSAIDs, continuous use is preferred if needed to control symptoms.
Patients should be educated about axSpA and encouraged to exercise on a regular basis and stop smoking; physiotherapy should be considered.
By suppressing inflammation, NSAIDs often suffice in keeping disease activity and symptoms under control.
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