Treatment of Ankylosing Spondylitis with Peripheral Arthritis
Clinical Scenario
This protocol is for patients with ankylosing spondylitis who present with peripheral arthritis — involvement of joints beyond the axial skeleton. This manifestation directly influences treatment selection, as management recommendations differ from those for purely axial disease.
Peripheral Arthritis in AS
Patients with predominantly peripheral manifestations follow a distinct treatment pathway. Conventional disease-modifying therapy plays a limited role in pure axial disease, but may be considered when peripheral joints are involved. Escalation criteria for this group account for peripheral joint activity alongside axial disease burden.
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Treatment target: A clinically important improvement in disease activity — defined as an ASDAS decrease of ≥1.1 — assessed after at least 12 weeks of therapy.
Treatment Approach
When disease activity remains high despite conventional management, biologic therapy is the next step. Current evidence supports a specific class of biologic agent as the preferred starting point — the full protocol defines the options, selection criteria, and what is assessed for continuation.
References
DOI: 10.1136/ard-2022-223296
- 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.
- 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.
- 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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