Table 10 Assessment of SpondyloArthritis international Society (ASAS)/European League Against Rheumatism (EULAR) recommendations for the management of ankylosing spondylitis (AS)27
No.Proposition
1Treatment of AS should be tailored according to:
Current manifestations of the disease (axial, peripheral, entheseal, extra-articular symptoms and signs)
Level of current symptoms, clinical findings and prognostic indicators:
    Disease activity/inflammation
    Pain
    Function, disability, handicap
    Structural damage, hip involvement, spinal deformities
General clinical status (age, sex, comorbidity, concomitant drugs)
Wishes and expectations of the patient
2Disease monitoring of patients with AS should include patient history (for example, questionnaires), clinical parameters, laboratory tests and imaging, all according to the clinical presentation, as well as the ASAS core set; the frequency of monitoring should be decided on an individual basis depending on symptoms, severity and drug treatment.
3Optimal management of AS requires a combination of non-pharmacological and pharmacological treatments
4Non-pharmacological treatment of AS should include patient education and regular exercise. Individual and group physical therapy should be considered. Patient associations and self-help groups may be useful.
5NSAIDs are recommended as first line drug treatment for patients with AS with pain and stiffness. In those with increased GI risk, non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor could be used.
6Analgesics, such as paracetamol and opioids, might be considered for pain control in patients in whom NSAIDs are insufficient, contraindicated and/or poorly tolerated.
7Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered. The use of systemic corticosteroids for axial disease is not supported by evidence.
8There is no evidence for the efficacy of DMARDs, including sulfasalazine and methotrexate, for the treatment of axial disease. Sulfasalazine may be considered in patients with peripheral arthritis.
9Anti-TNF treatment should be given to patients with persistently high disease activity despite conventional treatments according to the ASAS recommendations. There is no evidence to support the obligatory use of DMARDs before, or concomitant with, anti-TNF treatment in patients with axial disease.
10Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age. Spinal surgery, for example, corrective osteotomy and stabilisation procedures, may be of value in selected patients.
  • COX-2, cyclo-oxygenase 2; DMARDs, disease-modifying antirheumatic drugs; GI, gastrointestinal; NSAIDs, non-steroidal anti-inflammatory drugs; TNF, tumour necrosis factor.