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In April 2006, an international panel of experts from the Assessment in Ankylosing Spondylitis (ASAS) working group and the European League Against Rheumatism (EULAR) published a group of evidence-based recommendations for the management of patients with AS. These recommendations were published in the Annals of Rheumatic Diseases , Volume 45(4):442-452, April 2006. You can access the abstract of this article at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&listuids=16126791&queryhl=23&itool=pubmed_docsum

Based upon the experience of 22 experts in the field of ankylosing spondylitis (rheumatologists and orthopedic surgeons) and a systematic review of the published medical literature, the joint ASUS/EULAR international working group issued the following recommendations pertaining to the management of patients with ankylosing spondylitis:

• Treatment of ankylosing spondylitis should be based on the patient's clinical profile including:

  • areas of the body affected
  • severity of the signs and symptoms
  • extent of disease activity and inflammation
  • level of pain
  • extent of functional disability
  • patient preference for treatment

• Evaluation and monitoring of patients with ankylosing spondylitis should include:

  • patient history
  • physical examination
  • laboratory studies
  • imaging studies - X-rays of the cervical and lumbar spine usually at 2-year intervals to evaluate changes over time

• Patients with ankylosing spondylitis are managed best using a combined approach of non-drug therapy and medications.

• Non-drug therapy for ankylosing spondylitis should include:

  • patient education about the condition
  • physical therapy
  • exercise
  • encourage participation in patient associations and support groups

• The following recommendations pertain to the management of AS patients with drug therapy:

  • NSAIDs are considered as the first choice drugs for AS patients with pain and stiffness.
  • More potent pain medications, such as paracetamol and opioids, may be considered for patients whose pain cannot be adequately controlled with NSAIDS or who develop severe side effects from NSAIDs.
  • Long-term studies of DMARDs (sulfasalzine and methotrexate) do not show a significant beneficial effect on either spinal pain or spinal function (axial disease) in patients with AS and these drugs should not be used in patients with axial disease.
  • There is limited evidence supporting the efficacy of sulfasalazine, but not methotrexate, for controlling the symptoms of peripheral arthritis in patients with AS.
  • Treatment of AS patients with anti-tumor necrosis factor agents (e.g., infliximab, etanercept, adalimumab) should be restricted to patients who continue to exhibit high disease activity despite attempts to control the disease through more conventional treatments.

• Patients with ankylosing spondylitis who continue to have unremitting pain despite all efforts to control the disease with more conservative approaches to treatment (physical therapy and drug therapy), may be considered candidates for surgery including hip replacement surgery or spinal surgery to correct spinal instability and/or spinal deformity.