REVIEW

Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis

J Zochling¹, D van der Heijde², M Dougados³, J Braun⁴

¹ Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Herne, Germany, and Institute of Bone and Joint Research, Royal North Shore Hospital, Sydney, Australia
² Department of Internal Medicine,Division of Rheumatology, University Hospital Maastrict and Caphri Research Institute, The Netherlands
³ Service de Rheumatologie B, Hospital Cochin, Paris, France
⁴ Bochum University and Rheumazentrum Ruhrgebiet, St Josefs-Krankenhaus, Herne, Germany

Correspondence to:
Professor J Braun
Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Landgrafenstr 15, 44652 Herne, Germany; J.Braun{at}rheumazentrum-ruhrgebiet.de

Objective: To assess available management strategies in ankylosing spondylitis (AS) using a systematic approach, as a part of the development of evidence based recommendations for the management of AS.

Methods: A systematic search of Medline, Embase, CINAHL, PEDro, and the Cochrane Library was performed to identify relevant interventions for the management of AS. Evidence for each intervention was categorised by study type, and outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated for each intervention where possible. Results from randomised controlled trials were pooled where appropriate.

Results: Both pharmacological and non-pharmacological interventions considered to be of interest to clinicians involved in the management of AS were identified. Good evidence (level Ib) exists supporting the use of non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs for symptomatic treatment. Non-pharmacological treatments are also supported for maintaining function in AS. The use of conventional antirheumatoid arthritis drugs is not well supported by high level research evidence. Tumour necrosis factor inhibitors (infliximab and etanercept) have level Ib evidence supporting large treatment effects for spinal pain and function in AS over at least 6 months. Level IV evidence supports surgical interventions in specific patients.

Conclusion: This extensive literature review forms the evidence base considered in the development of the new ASAS/EULAR recommendations for the management of AS.

Abbreviations: AS, ankylosing spondylitis; ASAS, ASsessment in AS; CI, confidence interval; DMARDs, disease modifying antirheumatic drugs; ES, effect size; GI, gastrointestinal; IV, intravenous; MeSH, medical subject heading; NNT, number needed to treat; NSAIDs, non-steroidal anti-inflammatory drugs; RCT, randomised controlled trial; RR, relative risk; THR, total hip replacement; TNF, tumour necrosis factor

Keywords: ankylosing spondylitis; evidence based medicine; systematic review

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