What Is the Best Medication for Ankylosing Spondylitis?

According to rheumatologists, there is no single best medication for ankylosing spondylitis (AS) because each person responds differently to therapy. The optimal treatment approach is highly individualized and depends on the severity of symptoms, disease activity, and which joints are affected. A combination of different medication classes, often alongside exercise and physical therapy, is the most effective strategy for managing this chronic inflammatory condition.

Quick Summary

This guide covers the various medication classes for managing ankylosing spondylitis, including first-line NSAIDs, targeted biologics, and oral JAK inhibitors. It details the mechanisms, uses, and side effects of each type, helping readers understand the options available for creating a personalized treatment plan.

Key Points

• Personalized Treatment: There is no universal "best" medication for ankylosing spondylitis (AS); treatment plans are highly individualized based on disease activity and symptoms.

• First-Line NSAIDs: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are the initial treatment step for reducing pain and inflammation, though they are not sufficient for everyone.

• Effective Biologics: If NSAIDs fail, targeted biologics like TNF inhibitors (e.g., Humira) and IL-17 inhibitors (e.g., Cosentyx) are very effective at controlling inflammation and slowing disease progression.

• Oral JAK Inhibitors: Newer oral medications called JAK inhibitors (e.g., Xeljanz, Rinvoq) offer an alternative for patients who don't respond to or can't tolerate biologics, though they carry specific safety warnings.

• Comprehensive Management: The most successful outcomes involve a combination of medication, regular exercise, and physical therapy to maintain flexibility and strength.

• Regular Monitoring: Finding the right medication and dosage requires ongoing monitoring and communication with a rheumatologist to track progress and manage potential side effects.

A Personalized Approach to Ankylosing Spondylitis Treatment

Ankylosing Spondylitis (AS) is a chronic, progressive form of inflammatory arthritis primarily affecting the spine and sacroiliac joints. The disease can cause significant pain, stiffness, and long-term disability if left untreated, as inflammation can lead to the fusion of vertebrae. Fortunately, advancements in pharmacology offer numerous options for managing symptoms, slowing disease progression, and improving quality of life. The search for the “best” medication is less about finding a universal cure and more about discovering the most effective, personalized regimen for an individual's specific needs. This approach typically begins with less aggressive options and progresses to more targeted therapies if needed.

First-Line Treatment: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

For most people diagnosed with AS, the treatment journey starts with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). These medications work by blocking enzymes that promote inflammation and pain in the body. While over-the-counter NSAIDs like ibuprofen and naproxen can be used, prescription-strength doses are often necessary for managing AS.

Common NSAIDs for AS include:

• Naproxen (Aleve)
• Ibuprofen (Advil, Motrin)
• Celecoxib (Celebrex), a COX-2 inhibitor with a lower risk of gastrointestinal bleeding
• Indomethacin (Indocin)
• Meloxicam (Mobic)

NSAIDs are typically taken daily, rather than as needed, to stay ahead of the pain and inflammation. However, long-term use, especially at high doses, carries risks, including gastrointestinal bleeding, kidney problems, and an increased risk of cardiovascular events. For those who cannot tolerate NSAIDs or whose symptoms are not adequately controlled, a rheumatologist will move on to more advanced therapies.

Targeted Therapy: Biologics

Biologics are a class of medications made from living cells that target specific inflammatory proteins in the immune system. They are often the next step for individuals whose spinal inflammation does not improve with NSAIDs. Biologics are highly effective at reducing inflammation, pain, and stiffness, and can help prevent further spinal damage. These are administered via injection or intravenous (IV) infusion.

TNF Inhibitors

Tumor Necrosis Factor (TNF) inhibitors were the first class of biologics approved for AS and are often the first biologic a doctor will prescribe. They work by blocking TNF-alpha, a key protein involved in the inflammatory process.

Approved TNF inhibitors for AS include:

• Adalimumab (Humira)
• Etanercept (Enbrel)
• Infliximab (Remicade)
• Certolizumab pegol (Cimzia)
• Golimumab (Simponi)

IL-17 Inhibitors

For patients who do not respond to TNF inhibitors, another class of biologics, Interleukin-17 (IL-17) inhibitors, may be recommended. They block the IL-17A protein, which also plays a significant role in causing inflammation.

Approved IL-17 inhibitors for AS include:

• Secukinumab (Cosentyx)
• Ixekizumab (Taltz)

Oral Alternatives: JAK Inhibitors

Janus Kinase (JAK) inhibitors represent a newer class of oral medications that interfere with the signaling pathways that trigger inflammation inside immune cells. They are typically used for adults with active AS who have not responded well to TNF inhibitors.

Approved JAK inhibitors for AS include:

• Tofacitinib (Xeljanz)
• Upadacitinib (Rinvoq)

Unlike biologics, JAK inhibitors are taken orally, which some patients may prefer. However, they carry serious side effect warnings, including increased risks of cardiovascular events, cancer, and blood clots.

Other Medications and Therapies

In addition to the primary treatments, other medications and therapies may be used to manage specific aspects of AS.

These may include:

• Disease-Modifying Antirheumatic Drugs (DMARDs): Conventional DMARDs, like sulfasalazine and methotrexate, are generally not effective for spinal inflammation but can treat peripheral joint involvement (e.g., in the hips or knees).
• Corticosteroid Injections: Injections of corticosteroids directly into a specific inflamed joint or enthesis (where tendons and ligaments attach to bone) can provide temporary, localized relief from pain and swelling. Oral steroids are generally not recommended for widespread AS symptoms.
• Pain Relievers and Muscle Relaxants: Stronger painkillers, like codeine, and muscle relaxants can be used for short-term, severe pain relief, but they do not address the underlying inflammation.
• Physical Therapy and Exercise: Alongside medication, regular physical therapy and a consistent exercise routine are crucial for maintaining mobility, reducing stiffness, improving posture, and overall well-being.

Finding the Right Fit for You

Determining the best medication for ankylosing spondylitis is a collaborative process between you and your rheumatologist. The choice will be guided by your specific symptoms, the severity and location of inflammation, other health conditions you may have, and your personal preferences for medication delivery (oral vs. injection). You should be continuously monitored for response and side effects, and your treatment plan may evolve over time. Finding the right regimen is a matter of trial and error, but with consistent communication with your healthcare team, significant symptom control and improved quality of life are achievable.

Comparison of Common Ankylosing Spondylitis Medications

Feature	NSAIDs	TNF Inhibitors	IL-17 Inhibitors	JAK Inhibitors
Mechanism	Blocks enzymes that cause inflammation and pain.	Targets and blocks the TNF-alpha inflammatory protein.	Targets and blocks the IL-17A inflammatory protein.	Blocks intracellular signaling that leads to inflammation.
Primary Use	First-line treatment for pain, stiffness, and inflammation.	Used when NSAIDs are insufficient to control spinal inflammation.	Used for patients who do not respond to or tolerate TNF inhibitors.	Oral alternative for patients not responding to TNF inhibitors.
Administration	Oral tablets.	Injections (e.g., Humira, Enbrel) or IV infusions (e.g., Remicade).	Self-injected subcutaneously or IV infusion.	Oral tablets.
Common Examples	Naproxen, Ibuprofen, Celecoxib.	Adalimumab, Etanercept, Infliximab.	Secukinumab, Ixekizumab.	Tofacitinib, Upadacitinib.
Onset of Action	Relatively quick.	3 to 6 months.	Variable; can be effective after TNF inhibitors fail.	Around 6 to 8 weeks.
Potential Side Effects	GI issues, high blood pressure, cardiovascular risks.	Increased infection risk (including TB), injection site reactions.	Increased infection risk, potential for IBD onset.	Increased risk of serious heart events, cancer, blood clots.

Conclusion

While there is no single best medication for ankylosing spondylitis, there is a clear treatment pathway that starts with NSAIDs and can progress to highly effective biologics or JAK inhibitors. The goal of this progressive approach is to achieve a state of low disease activity or even remission, preventing irreversible joint damage and spinal fusion. The optimal strategy involves a multidisciplinary approach, combining medication with essential therapies like exercise and physical therapy. Patients should work closely with their rheumatologist to find the regimen that best controls their symptoms, minimizing side effects and allowing them to lead a full and active life.

For more in-depth information and patient support, consult the American College of Rheumatology/Spondylitis Association of America (ACR/SAA) recommendations.

Frequently Asked Questions

What is the first medication prescribed for ankylosing spondylitis?

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are typically the first-line treatment for ankylosing spondylitis. These medications, such as naproxen and ibuprofen, help reduce pain and inflammation.

Are biologics better than NSAIDs for ankylosing spondylitis?

Biologics are often more effective for managing severe ankylosing spondylitis, especially spinal inflammation that doesn't respond to NSAIDs. While NSAIDs are the first step, biologics provide more targeted, long-term disease modification for many patients.

Can I take oral medication instead of injections for ankylosing spondylitis?

Yes. While many biologics are given via injection or infusion, oral JAK inhibitors like Xeljanz (tofacitinib) and Rinvoq (upadacitinib) are available as alternatives for patients who haven't responded to other treatments.

What are TNF inhibitors and how do they help with ankylosing spondylitis?

TNF inhibitors are a class of biologic drugs that block a protein called Tumor Necrosis Factor (TNF), which drives inflammation in the body. By blocking this protein, they can significantly reduce inflammation, pain, and stiffness associated with ankylosing spondylitis.

How do IL-17 inhibitors differ from TNF inhibitors?

IL-17 inhibitors are a different type of biologic medication that targets the IL-17A protein, another key player in the inflammatory response. They are often prescribed to patients with ankylosing spondylitis who do not achieve adequate relief from TNF inhibitors.

Are there side effects associated with ankylosing spondylitis medications?

Yes, all medications have potential side effects. NSAIDs can cause gastrointestinal issues and affect blood pressure. Biologics and JAK inhibitors suppress the immune system, increasing the risk of infection, and JAK inhibitors carry specific warnings regarding heart-related events.

Is exercise important alongside medication for ankylosing spondylitis?

Yes, exercise is a crucial component of ankylosing spondylitis treatment. Regular physical therapy and exercise routines help maintain spinal mobility, reduce stiffness, and improve overall physical function, complementing the effects of medication.