This protocol applies to patients with ankylosing spondylitis who also have significant psoriasis. The presence of clinically significant psoriasis is a key factor that shapes which therapy is appropriate at this stage.
The first-line approach — NSAIDs at the maximum tolerated dose, with education about the condition, regular exercise, smoking cessation, and physiotherapy — aims to bring back pain and spinal stiffness under control within 2–4 weeks. When that goal is not achieved, the next treatment step is indicated.
When ankylosing spondylitis is accompanied by significant psoriasis, the skin involvement guides the selection of biologic therapy. A specific class of biologic agent is preferred in this setting, with success defined as a clinically important reduction in disease activity — measured by an ASDAS decrease of at least 1.1 after a minimum of 12 weeks — alongside meaningful improvement in psoriasis skin outcomes.
The complete regimen, continuation criteria, and full decision algorithm are available in the structured protocol.
DOI: 10.1136/ard-2022-223296
In patients with significant psoriasis, an IL-17i may be preferred.
Two head-to-head trials have been conducted comparing IL-17i (secukinumab and ixekizumab) with TNFi (adalimumab in both trials), showing superiority of IL-17i in the achievement of robust skin outcomes.
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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