ASAS-EULAR* recommendations for the management of axSpA stress the importance of pharmaceutical (drugs or medications) and non-pharmaceutical treatments together. This may require life style changes to build more activity into your life for optimal outcomes.
There are relatively few drugs approved for axSpA but new medications are being developed all the time. The most effective category of drugs for axSpA is biologics. Unfortunately, until precision or personalized medicine is better perfected, it is not known which biologic may be best suited to you. This means that at present you may have to try two or more biologics before you find one that is effective for you.
There are some global differences in brand names of drugs and accessibility to them varies
* ASAS – Assessment of Spondyloarthritis International Society. EULAR – European Alliance of Associations for Rheumatology.
globally. Nevertheless, we have followed recommended treatment options in this brochure. ASIF advocates for equal accessibility to effective medications globally.
Why take drugs? Medications recommended for axSpA can help with reducing inflammation and relieving pain. However, they cannot cure or reverse the effects of the disease. There is evidence that treatment with biologic drugs can significantly reduce the progress of disease and also, if started early enough, can lead to a high chance of remission. Both outcomes improve the quality of the patient’s life.
- Pharmacological Treatments
a) NSAIDS/Cox-2 Inhibitors.
NSAIDs or Nonsteroidal Anti-Inflammatory Drugs are the first treatment option because they are effective in reducing pain and stiffness.
Typical NSAIDs are aspirin, ibuprofen and naproxen. They are available in a healthcare provider should monitor you for any adverse side-effects.
Local glucocorticoid injections may be prescribed for persistent joint inflammation, but long-term treatment by systemic glucocorticoids is not recommended and should be avoided.
b) Analgesics.
Analgesics (pain relievers) may be prescribed when other treatments have been poorly tolerated or failed to control or eliminate pain. Non-narcotic analgesics are used today.
c) bDMARDs
Biologic Disease Modifying Anti-Rheumatic Drugs, or biologics for short, started coming to market in the late 1990s. They were a welcome addition to drugs for axSpA, for which NSAIDs had been the main treatment.
Biologics are taken by infusion or injection in doses and at intervals determined by your rheumatologist.
There have been many biologics developed since the late 1990s but not all are approved for axSpA. The first approvals for axSpA were for Tumor Necrosis Factor, TNF, Inhibitors. These include adalimumab, certolizumab, etanercept, golimumab and infliximab. In 2015, secukinumab, which suppresses Interleukin 17 and is known as an IL-17 Inhibitor, was approved for axSpA. Several other IL-17 Inhibitors have been developed of which ixekizumab was approved for axSpA in 2019. Other biologics have been developed or are in trial for axSpA, for example IL-23 and Il-6 Inhibitors, but have not yet shown any efficacy in axSpA. Tofacitinib is a small-molecule JAK Inhibitor taken in pill form that is being prescribed off-label for some axSpA patients, with positive results.
You may be prescribed a biosimilar. As originator biologics come off patent, it allows other manufacturers to produce that same biologic. In this case, the new manufacturer produces a biosimilar. Biosimilars have the same safety and efficacy profile as the originator biologic. They are usually cheaper than the originator because they have been produced with more advanced techniques and technology.
d) csDMARDS
Conventional Synthetic Disease-Modifying Drugs include methotrexate and sulfasalazine, neither of which are recommended for axSpA because of their lack of efficacy. However, they are often prescribed to supplement other treatments and sulfasalazine is recommended for peripheral disease.
2. Non-Pharmaceutical Treatments:
a) Exercise
The role of exercise in managing your disease cannot be emphasised enough. Exercise is necessary to maintain flexibility, range of motion and good posture. Exercise has many other benefits such as reducing pain, stiffness and fatigue. Please refer to our Exercise brochure for more information. Remember that any activity is better than no activity; that exercising in a group is better than exercising alone, and that any exercise regimen should include elements of stretching, strength and stamina.
Yoga, tai chi and Pilates are low-impact forms of exercise that are popular.