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The "gold standard" of treatment for ankylosing spondylitis (AS) is non-steroidal anti-inflammatory medications (NSAIDs) combined with physical therapy. Though there are no treatments that result in slowing, changing, or stopping the inflammatory process, NSAIDs are vital for reducing pain and maintaining the conditioning of the spine and other affected areas.

In general, medications that may be used for the treatment of patients with ankylosing spondylitis include:

• Non-Steroidal Antiinflammatory Drugs (NSAIDs)
• Disease Modifying Antirheumatic Drugs (DMARDs)
• Corticosteroids
• Bisphosphonates
• Anti-TNF-alpha Drugs

NSAIDs have been used since the 1940s to treat ankylosing spondylitis and are effective for controlling pain in the majority of patients with ankylosing spondylitis (up to 80%). DMARDs were initially introduced in the 1930s and, although several newer types of DMARDs have become available on the market, they have never proven to be as effective for ankylosing spondylitis as they have for rheumatoid arthritis. The anti-inflammatory properties of corticosteroids have been known for many decades, however, they do not alter the disease process of ankylosing spondylitis, but rather merely suppress the extent of the inflammation. If the patient is unresponsive to one type of medication, then another type is introduced.

Biological agents such as anti-TNF-alpha represent the first hope for potentially changing the disease progression of ankylosing spondylitis by targeting specific inflammatory processes. TNF-alpha is a proinflammatory cytokine (immune system mediator that plays an important role in inducing inflammation) that has been implicated in the pathogenesis of both rheumatoid arthritis (RA) and in Crohn's disease. In both of these conditions, doctors have discovered that inhibiting the production and activity of TNF-alpha brings relief of symptoms to patients and effectively controls the severity of the condition. Several clinical trials have shown that anti-TNF-alpha agents are active in altering the progression of ankylosing spondylitis.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are anti-inflammatory agents that suppress the chronic inflammation associated with ankylosing spondylitis and, thereby, alleviate pain, stiffness, and discomfort. In general, NSAIDs are effective for controlling symptoms of ankylosing spondylitis in about 70-80% of patients. Examples of NSAIDs that are available "over-the-counter" (without a prescription) include:

• Aspirin (e.g., Anacin, Bayer)
• Ibuprofen (e.g., Motrin, Advil)
• Naproxen sodium (e.g., Aleve)
• Ketoprofen (e.g., Orudis, Actron)

Examples of NSAIDs that are available by prescription only include:

• Diclofenac (e.g., Voltaren)
• Etodolac (e.g., Lodine)
• Indomethacin (e.g., Indocin)
• Piroxicam (e.g., Feldene)

NSAIDs can cause gastrointestinal side-effects in some patients when taken either for a long time or in high doses. They reduce the mucus lining of the stomach which can lead to irritation and can cause stomach pain, heartburn, stomach ulcers, and/or bleeding. Side effects of NSAIDs can be offset by other medications including:

• Antacids (e.g., Pepto-Bismol)
• Drugs that coat the lining of the stomach (e.g. Carafate)
• Drugs that restore mucous, such as misoprostol (Cytotec)

A newer class of NSAIDs known as the cyclooxygenase-2- inhibitors (COX-2 inhibitors) appears to reduce the gastrointestinal side-effects that are associated with other NSAIDs. Examples of COX-2 inhibitors include celecoxib (Celebrex) and rofecoxib (Vioxx), both of which have been taken off the market due to increased risk of cardiovascular events including heart attack and stroke. The older NSAIDs and the newer COX-2 inhibitors appear to be equally effective for controlling the symptoms of ankylosing spondylitis.

Disease Modifying Antirheumatic Drugs (DMARDs)