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Ankylosing spondylitis

Definition
AS is a chronic inflammatory disease characterized by arthritis of the spine and the sacroiliac joints.
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Pathophysiology
AS is strongly associated with the HLA-B27 genotype, although most persons with this genotype do not develop the disease. The etiology of joint inflammation in patients with AS involves the interaction of genetic predisposition and environmental factors with alterations in immune cell function, and cytokine regulation.
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Epidemiology
In the US, the annual incidence and prevalence of AS are 3.1 cases per 100,000 person-years and 197 persons per 100,000 population, respectively.
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Disease course
Clinical manifestations of AS include arthritis, dactylitis, ankylosis, osteoporosis of the spine and peripheral bones, uveitis, and IBD.
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Prognosis and risk of recurrence
Patients with AS have an increased risk of mortality, with an estimated standardized mortality ratio of 1.61. CVD is the most frequent cause of death (40%), followed by malignant (27%) and infectious (23%) diseases.
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Key sources
The following summarized guidelines for the evaluation and management of ankylosing spondylitis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023), the European League Against Rheumatism (EULAR 2022), the Assessment of SpondyloArthritis international Society (ASAS/EULAR 2022), the American College of Radiology (ACR 2021; 2017), the Spondyloarthritis Research and Treatment Network (SPARTAN/ACR/SAA 2019), and the British Society for Rheumatology (BSR/BHPR 2017).
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Guidelines

1.Classification and risk stratification

Severity assessment: measure BASDAI on 2 occasions at least 4 weeks apart.
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define the disease as active if BASDAI and spinal pain VAS score is ≥ 4 despite standard therapy.
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2.Diagnostic investigations

Diagnostic imaging: as per ACR 2021 guidelines, obtain radiography of sacroiliac joints or sacroiliac joints and spine area of interest as the initial imaging of suspected axSpA.
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  • Screening for osteoporosis

  • Screening for heart diseases

  • Screening for chronic infections

3.Medical management

General principles: as per ASAS 2022 guidelines, individualize treatment of patients with axSpA according to the current signs and symptoms of the disease (axial, peripheral, extra-musculoskeletal manifestations) and the patient characteristics including comorbidities and psychosocial factors. Guide treatment according to a predefined treatment target.
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  • Management of active AS (NSAIDs)

  • Management of active AS (DMARDs)

  • Management of active AS (biologic agents)

  • Management of active AS (corticosteroids)

  • Management of stable AS

  • Management of pain

  • Management of uveitis

4.Nonpharmacologic interventions

Smoking cessation: advise smoking cessation in patients with AS.
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  • Physical therapy

  • Spinal manipulation

5.Therapeutic procedures

Local corticosteroid injections: as per ASAS 2022 guidelines, consider administering corticosteroid injections directed to the local site of musculoskeletal inflammation.
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6.Surgical interventions

Spinal osteotomy: as per EULAR 2022 guidelines, consider performing spinal corrective osteotomy in patients with severe disabling deformity in specialized centers.
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7.Specific circumstances

Patients with inflammatory bowel disease: as per ASAS 2022 guidelines, prefer monoclonal antibodies against TNF in patients with active IBD.
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8.Patient education

General counseling: as per ASAS 2022 guidelines, educate patients with axSpA about their condition.
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9.Preventative measures

Routine immunizations: consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in ≥ 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications.
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  • Prophylaxis for P. jirovecii pneumonia

10.Follow-up and surveillance

Monitoring of disease activity: as per ASAS 2022 guidelines, assess patient-reported outcomes and clinical findings, obtain laboratory tests and imaging, all with the appropriate instruments and relevant to the clinical presentation, for disease monitoring of patients with axSpA. Decide on the frequency of monitoring on an individual basis depending on symptoms, severity, and treatment.
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  • Assessment of treatment response