Ankylosing Spondylitis Treatment

The primary goals of treating ankylosing spondylitis are to reduce inflammation, relieve symptoms, and prevent progression. ¹ Wenker KJ, Quint JM. Ankylosing Spondylitis. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470173/

Treatment strategies, including medication, physical therapy, and lifestyle changes target the cause of inflammation and improve or maintain the function and mobility of the spine and affected joints. ¹ Wenker KJ, Quint JM. Ankylosing Spondylitis. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470173/

Medications for Ankylosing Spondylitis

Most cases of ankylosing spondylitis require medication therapy to manage inflammation and slow disease progression. 

The following tables lists the types of medications used to treat ankylosing spondylitis.

Specific treatment recommendations for dosing and combining drug therapies vary depending on whether ankylosing spondylitis symptoms are active or in remission. ³ Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042

See Pain Medications for Arthritis Pain Relief

Duration of medication therapy for ankylosing spondylitis

Ankylosing spondylitis is a chronic condition that, in most cases, requires continued treatment even when the disease is in remission (stable). Continued treatment helps keep inflammation and immune activity in control. ² Sen R, Goyal A, Hurley JA. Seronegative Spondyloarthropathy. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459356/ ^{, 3} Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042

When the symptoms of ankylosing spondylitis are stable, meaning pain and function are improved and inflammation is controlled, long-term therapy with TNFi or IL-17 inhibitors helps prevent relapse or flare-ups. Drugs such as NSAIDs and DMARDs are not preferred for long-term symptom control due to the potential risk of gastrointestinal and cardiac side effects. ² Sen R, Goyal A, Hurley JA. Seronegative Spondyloarthropathy. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459356/ ^{, 3} Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042

Physical Therapy and Exercise for Ankylosing Spondylitis

Rehabilitation programs including physical therapy and regular exercise effectively manage pain and improve mobility and flexibility in ankylosing spondylitis. When used with or without medication therapy, physical therapy and exercise have been shown to reduce disease activity and improve function significantly. ⁴ Millner JR, Barron JS, Beinke KM, et al. Exercise for ankylosing spondylitis: An evidence-based consensus statement. Seminars in Arthritis and Rheumatism. 2016;45(4):411-427. doi: 10.1016/j.semarthrit.2015.08.003 ^{, 5} Giannotti E, Trainito S, Arioli G, Rucco V, Masiero S. Effects of physical therapy for the management of patients with ankylosing spondylitis in the biological era. Clinical Rheumatology. 2014;33(9):1217-1230. doi:10.1007/s10067-014-2647-6

Therapeutic activities recommended for ankylosing spondylitis include ³ Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042 ^{, 6} Spondyloarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2017 Jun. (NICE Guideline, No. 65.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK553609/ :

• Stretching exercises, such as neck rotation and hip flexor stretches
• Strength training, such as yoga, Pilates, and weight training
• Guided relaxation, such as Tai Chi and deep breathing
• Low-impact aerobic exercises, such as biking or swimming
• Hydrotherapy, including water-based exercises and hydro-electric baths

Routine exercise also aids in increasing lung capacity and improving heart health, which lowers the risk of respiratory and cardiac complications. ⁴ Millner JR, Barron JS, Beinke KM, et al. Exercise for ankylosing spondylitis: An evidence-based consensus statement. Seminars in Arthritis and Rheumatism. 2016;45(4):411-427. doi: 10.1016/j.semarthrit.2015.08.003

See Exercising with Arthritis

Consulting a specialist, such as a physical therapist or occupational therapist, is advisable for individualized exercise plans and to learn the techniques to perform the movements safely and effectively.

Healing Treatments for Ankylosing Spondylitis

Modifying daily habits to sustain a healthy lifestyle enhances the quality of life and reduces the risk of complications in individuals with ankylosing spondylitis. Specific changes include ⁷ Danve A, Deodhar AA. Complementary medicine for axial spondyloarthritis: is there any scientific evidence?. Curr Opin Rheumatol. 2018;30(4):310-318. doi:10.1097/BOR.0000000000000513 ^{- 10} Ellulu MS, Patimah I, Khaza'ai H, Rahmat A, Abed Y. Obesity and inflammation: the linking mechanism and the complications. Arch Med Sci. 2017;13(4):851-863. doi:10.5114/aoms.2016.58928 :

• Anti-inflammatory diet. Incorporating foods with anti-inflammatory properties (eg, whole grains and omega-3 fatty acids) and avoiding or limiting foods that trigger inflammation (eg, alcohol and sugar) helps to improve gut health and relieve symptoms.
• Ergonomic adjustments. Individuals who spend significant time sitting at a desk are encouraged to take breaks, change positions, and stretch regularly. 
• Supportive devices. The use of lumbar support pillows, back braces, or zero-gravity chairs helps to reduce pain and promote a supportive posture.
• Smoking cessation. Smoking is associated with an increased risk of respiratory and cardiac conditions. Smoking cessation is advisable to reduce the risk of these complications.
• Weight management. Maintaining a healthy weight reduces the strain placed on joints by excess body weight and decreases the pro-inflammatory cells produced by body fat.

It is also advisable to avoid heavy lifting or strenuous exercises that place an increased strain on the back or other affected joints. ¹¹ Hwang MC, Ridley L, Reveille JD. Ankylosing spondylitis risk factors: a systematic literature review. Clin Rheumatol. 2021;40(8):3079-3093. doi:10.1007/s10067-021-05679-7

Injection Treatments for Ankylosing Spondylitis

Local injections of corticosteroids, such as triamcinolone, are potentially beneficial for patients with sacroiliitis and/or peripheral arthritis who have not responded to oral medications, such as NSAIDs, DMARDs, or biologics. ³ Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042 ^{, 12} Kokar S, Kayhan Ö, Şencan S, Gündüz OH. The Role of Sacroiliac Joint Steroid Injections in the Treatment of Axial Spondyloarthritis. Arch Rheumatol. 2021;36(1):80-88. Published 2021 Jan 14. doi:10.46497/ArchRheumatol.2021.8043

Injection treatments offer localized relief from inflammation and pain at the injection site; however, they do not influence the overall disease activity or inflammation in other regions of the body. ³ Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042 ^{, 12} Kokar S, Kayhan Ö, Şencan S, Gündüz OH. The Role of Sacroiliac Joint Steroid Injections in the Treatment of Axial Spondyloarthritis. Arch Rheumatol. 2021;36(1):80-88. Published 2021 Jan 14. doi:10.46497/ArchRheumatol.2021.8043

Complementary Treatments for Ankylosing Spondylitis

Several non-drug strategies help reduce stress and inflammation and aid in the management of pain and stiffness in ankylosing spondylitis. These treatments include ¹³ Ciprian L, Lo Nigro A, Rizzo M, et al. The effects of combined spa therapy and rehabilitation on patients with ankylosing spondylitis being treated with TNF inhibitors. Rheumatology International. 2011;33(1):241-245. doi:10.1007/s00296-011-2147-9 :

• Spa therapy, including mud packs and thermal (mineral-rich) baths
• Massage therapy, particularly deep-tissue massage
• Acupuncture, which involves the insertion of thin needles into specific points on the body to restore energy flow and reduce pain
• Moxibustion, which involves burning dried mugwort near particular points on the body to stimulate circulation

These treatments are most beneficial when combined with medication and physical therapy. ⁵ Giannotti E, Trainito S, Arioli G, Rucco V, Masiero S. Effects of physical therapy for the management of patients with ankylosing spondylitis in the biological era. Clinical Rheumatology. 2014;33(9):1217-1230. doi:10.1007/s10067-014-2647-6