Ankylosing spondylitis (AS) is the most common form of
spondyloarthropathy. Non-steroidal anti-inflammatory medications and exercise are used to manage the chronic inflammatory spinal
pain and stiffness. Up to 20% of patients have a peripheral inflammatory
arthritis, which is treated with standard disease-modifying
anti-rheumatic drugs especially
sulfasalazine and
methotrexate. Patients may also have extra-articular manifestations, such as
anterior uveitis, psoriasiform skin lesions and
inflammatory bowel disease. Anti-tumour
necrosis (TNF)
therapy has been used with great success in
rheumatoid arthritis. There are now good data of the efficacy of anti-TNF
therapies in the short and medium terms in AS.
Etanercept,
infliximab and
adalimumab have been shown in randomized placebo-controlled trials of short duration to significantly reduce disease activity, including
pain and stiffness as well as improving function, spinal movement and quality of life. It is hoped that long-term
therapy will prevent radiologic progression and
ankylosis and studies of long-term efficacy are awaited. Anti-TNF
therapies are generally well tolerated in AS. It is important to screen for
latent tuberculosis before the commencement of anti-TNF
therapy. The side-effect profile of anti-TNF
therapies in AS does not appear different from that in
rheumatoid arthritis. Currently, treatment with anti-TNF
therapy in AS is indicated in established disease with radiographic damage. There is evidence that response to
therapy is greater in patients with earlier disease and less damage. Future developments may see this
therapy extended to patients with pre-radiographic AS.