• Biologic therapy: A TNF inhibitor should be given to patients with persistently high disease activity despite conventional treatments according to ASAS recommendations. No evidence supports the obligatory use of DMARDs before or during treatment with a TNF inhibitor in patients with axial AS. No evidence supports a difference in the efficacy of the various TNF inhibitors on axial and articular/entheseal disease manifestations. In patients with inflammatory bowel disease, differences in the gastrointestinal efficacy of the various TNF inhibitors should be taken into account. No evidence supports the efficacy of any other biologic agent aside from TNF inhibitors in AS patients. Switching to a second TNF inhibitor may benefit AS patients, especially those who lose response to the first drug they receive.
• Surgery: Consider total hip arthroplasty in patients with refractory pain or disability and radiographic evidence of structural damage independent of age. Spinal corrective osteotomy may be considered in patients with severe disabling deformity. AS patients with an acute vertebral fracture need a consultation with a spinal surgeon.
• If a patient has a significant change in disease course, other causes of inflammation, such as a spinal fracture, should be considered and an appropriate evaluation, including imaging, should be done.
Dr. Braun has received research support from, been a consultant to, and served as a speaker for Abbott Laboratories, Amgen Inc., Bristol-Myers Squibb Co., Centocor Inc., Merck/Schering-Plough Pharmaceuticals, Merck Sharp and Dohme Corp., Novartis, Pfizer Inc./Wyeth, and Roche.