management of axial spondylitis

Last edited 07/2021 and last reviewed 10/2023

Management of axial spondyloarthritis

NSAIDs

• offer NSAIDs at the lowest effective dose to people with pain associated with axial spondyloarthritis, and think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
• if an NSAID taken at the maximum tolerated dose for 2–4 weeks does not provide adequate pain relief, consider switching to another NSAID.

Biological DMARDs – adalimumab, certolizumab pegol, etanercept, golimumab and infliximab for the treatment of ankylosing spondylitis and non-radiographic axial spondyloarthritis

• Adalimumab, certolizumab pegol, etanercept, golimumab and infliximab are recommended, within their marketing authorisations, as options for treating severe active ankylosing spondylitis in adults whose disease has responded inadequately to, or who cannot tolerate, NSAIDs. Infliximab is recommended only if treatment is started with the least expensive infliximab product. People currently receiving infliximab should be able to continue treatment with the same infliximab product until they and their NHS clinician consider it appropriate to stop
• Adalimumab, certolizumab pegol and etanercept are recommended, within their marketing authorisations, as options for treating severe non-radiographic axial spondyloarthritis in adults whose disease has responded inadequately to, or who cannot tolerate, NSAIDs
• choice of treatment should be made after discussion between the clinician and the patient about the advantages and disadvantages of the treatments available. This may include considering associated conditions such as extra-articular manifestations. If more than 1 treatment is suitable, the least expensive (taking into account administration costs and patient access schemes) should be chosen
• response to adalimumab, certolizumab pegol, etanercept, golimumab or infliximab treatment should be assessed 12 weeks after the start of treatment. Treatment should only be continued if there is clear evidence of response, defined as:
• a reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score to 50% of the pre-treatment value or by 2 or more units and
• a reduction in the spinal pain visual analogue scale (VAS) by 2 cm or more.
• treatment with another tumour necrosis factor (TNF)-alpha inhibitor is recommended for people who cannot tolerate, or whose disease has not responded to, treatment with the first TNF-alpha inhibitor, or whose disease has stopped responding after an initial response
• When using BASDAI and spinal pain VAS scores, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the responses to the questionnaires, and make any adjustments they consider appropriate

Biological DMARDs – secukinumab for the treatment of ankylosing spondylitis

• Secukinumab is recommended, within its marketing authorisation, as an option for treating active ankylosing spondylitis in adults whose disease has responded inadequately to conventional therapy (NSAIDs or TNF-alpha inhibitors). The drug is recommended only if the company provides it with the discount agreed in the patient access scheme.
• Assess the response to secukinumab after 16 weeks of treatment and only continue if there is clear evidence of response, defined as:
• a reduction in the BASDAI score to 50% of the pre-treatment value or by 2 or more units and
• a reduction in the spinal pain VAS by 2 cm or more
• When using BASDAI and spinal pain VAS scores, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the responses to the questionnaires, and make any adjustments they consider appropriate
  
  
• Secukinumab is an option for treating non-radiographic axial spondyloarthritis (2) with objective signs of inflammation (shown by elevated C-reactive protein or MRI) that is not controlled well enough with non-steroidal anti-inflammatory drugs (NSAIDs) in adults
  • if tumour necrosis factor (TNF)-alpha inhibitors are not suitable or do not control the condition well enough

Surgery for spondyloarthritis

• do not refer people with axial spondyloarthritis to a complex spinal surgeryservice to be assessed for spinal deformity correction unless the spinal deformity is:
• significantly affecting their quality of life and
• severe or progressing despite optimal non-surgical management (including physiotherapy).

Surgical interventions include (3,4):

• vertebral osteotomy to treat severe flexion deformity
• total hip replacement to treat affected hip joints

The most important item of self-management is that the patient must exercise and keep moving. Postural training can help prevent serious deformity.

Notes:

• if a person with axial spondyloarthritis presents with a suspected spinal fracture, refer them to a specialist to confirm the spinal fracture and carry out a stability assessment. After the stability assessment, the specialist should refer people with a potentially unstable spinal fracture to a spinal surgeon (1)

Reference:

• (1) NICE (2017). Spondyloarthritis in over 16s: diagnosis and management
• (2) NICE (July 2021).Secukinumab for treating non-radiographic axial spondyloarthritis
• (3) Prescriber (1999); 10 (13): 71-78.
• (4) Drug and Therapeutics Bulletin 2005; 43(3):19-22.