Czech Rheumatological Society recommendations for the treatment of ankylosing spondylitis


Authors: K. Pavelka
Authors‘ workplace: Revmatologický ústav Praha a Klinika revmatologie 1. LF UK Praha
Published in: Čes. Revmatol., 20, 2012, No. 1, p. 4-11.
Category: Recommendations for Treatment

Overview

Czech Rheumatological Society has issued the Recommendations for the treatment of ankylosing spondylitis (AS), which update the Recommendations from 2004. Successful treatment is based on an accurate and early diagnosis, which can be established using either the modified New York criteria or the recently published criteria of ASAS / EULAR for axial spondyloarthropathies. At baseline examination of each patient with AS the extent of the disease is determined (axial, peripheral, combined or extra-articular symptoms). In addition, the activity of the disease is numerically evaluated with BASDAI score being the universally recommended methodology. Therapy of AS should be complex and consists of non-pharmacological and pharmacological treatment or surgery. Non-pharmacological treatment is based on education of patients and their motivation for a lifelong active rehabilitation program. A combination of individual home exercise and group exercises under the supervision of a physiotherapist is of particular advantage. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the basic pharmacological means with positive effects in 70-80% of patients. NSAIDs with long half-life are recommended. A long-term, daily administration of NSAIDs was demonstrated to slow down the radiological progression of AS. There is no evidence that any DMARD was effective for the axial form of AS. Therefore there is no requirement of DMARD treatment prior to biological therapy. Most studies show some effect of sulfasalazine on peripheral forms of AS. Neither methotrexate nor systemic glucocorticoids were shown to be effective. On the contrary, administration of topical glucocorticoid injections to the sites of peripheral arthritis or enthesitis is recommended. Anti-TNF antagonists are the most effective treatment. The efficacy of anti-TNF therapy in AS is fast, strong and long-term. Although efficacy was demonstrated even in advanced forms of AS a better effect was observed in patients with shorter disease duration. For the treatment of AS etanercept, infliximab, adalimumab and golimumab are indicated. For the treatment with anti-TNF agents the patient should meet the following criteria: Diagnosis of AS according to the modified New York or ASAS criteria; Disease activity BASDAI ≥ 4 at two consecutive check-ups in the period of at least 4 weeks; A positive expert opinion; CRP > 10 mg / l; Absence of contraindication to treatment; Response to therapy should be observed at week 12 and is evaluated as the decrease in BASDAI by 50% or two and more (on a scale of 0-10). In patients with hip involvement who have refractory pain, substantial disability and radiographic destruction of the hip joint a total hip replacement regardless of age is recommended. Corrective osteotomy in patients with significant hyperkyphosis is another recommended surgical method. In case of a suspected vertebral compression fracture a neurosurgeon should be consulted.

Conclusion:
The new recommendations allow early diagnosis of AS and its intensive treatment, which should lead to reduced disability and improved quality of life of patients with AS.

Key words:
ankylosing spondylitis, anti-TNF therapy 


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Labels
Dermatology & STDs Paediatric rheumatology Rheumatology
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