Current guidelines for the drug treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is a systemic inflammatory rheumatic disease involving spinal and sacroiliac joints. This condition is responsible for back pain, stiffness and discomfort. Several drugs are currently available in the management of AS, and may be divided into 3 groups. The first includes nonsteroidal anti-inflammatory drugs (NSAIDs), which are the main drug group used in AS because they reduce pain and stiffness in most patients. Several NSAIDs are available but phenylbutazone is considered the NSAID of choice in AS. However, other NSAIDs give similar beneficial results and the medication of preference in specific to each patient. All NSAIDs share common gastrointestinal toxicity, and they should be administered during periods of flare-up of the disease. The second drug group that has been used in the treatment of patients with AS comprises analgesics, muscle relaxants and low dose corticosteroids. They can be considered as adjuvant therapy. These drugs are helpful when NSAIDs are poorly tolerated or ineffective. Second-line treatments or disease modifying antirheumatic drugs (DMARDs) are included in the third group. These drugs are required in cases of longstanding severe or refractory AS. Sulfasalazine has proven to be effective in such cases, leading to improvement in clinical and laboratory indices of disease activity. Beneficial results are mainly evident in patients with AS who have peripheral disease involvement. Other medications (such as methotrexate or gold salts, for instance) require properly designed controlled studies to evaluate their effectiveness in the treatment of this disorder, while immunosuppressive agents have little to offer in the management of patients with AS and require further studies. Some specific clinical features are observed in AS: enthesopathy may be treated with local injection of corticosteroids; sacroiliac joint pain may be managed by corticosteroid injection performed under fluoroscopic control or guided by computed tomography. The management of patients with AS includes some other procedures such as patient education, rest, a programme of physical exercise and physiotherapy. In parallel with pharmacotherapy, these procedures are of great importance in reducing stiffness and spinal ankylosis, and thus improve the patient's quality of life.