Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy Medication

Updated: Jul 17, 2018
  • Author: Lawrence H Brent, MD; Chief Editor: Herbert S Diamond, MD  more...
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Medication

Medication Summary

The goal of pharmacotherapy is to reduce morbidity and to prevent complications—specifically, by reducing the pain and inflammation associated with ankylosing spondylitis (AS).

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Nonsteroidal Anti-inflammatory Drugs

Class Summary

Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for reducing pain secondary to inflammation and systemic symptoms in AS patients. These agents reduce inflammatory symptoms of spinal and peripheral joint pain and morning stiffness and appear to have a modest disease-modifying effect on spinal disease. Cyclooxygenase-2 (COX-2) inhibitors appear to be as effective as traditional NSAIDs.

NSAIDs and COX-2 inhibitors may increase the risk of serious cardiovascular thrombotic events, myocardial infarction (MI), and stroke, which can be fatal. They also increase the risk of serious adverse gastrointestinal (GI) effects, including stomach or intestinal bleeding, ulceration, and perforation, which can also be fatal. Elderly patients are at greater risk for serious GI events.

Indomethacin (Indocin)

Indomethacin is thought to be the most effective NSAID for the treatment of AS, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Ibuprofen (Motrin IB, Advil, NeoPpofen)

Ibuprofen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)

Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Diclofenac (Voltaren, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.

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5-Aminosalicylic Acid Derivatives

Class Summary

5-Aminosalicylic acid derivatives inhibit prostaglandin synthesis and reduce the inflammatory response to tissue injury.

Sulfasalazine (Azulfidine, Azulfidine EN-tabs)

Sulfasalazine has been shown to reduce the inflammatory symptoms of AS in controlled studies; its most common toxicities include nausea, diarrhea, and hypersensitivity reactions (rash).

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DMARDs, TNF Inhibitors

Class Summary

Tumor necrosis factor alpha (TNF-α) antagonists are biologic agents and include etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol. These agents inhibit TNF-α and have been shown to improve symptoms and function in AS patients in clinical trials. All have been approved for the treatment of AS. These agents are also all approved for the treatment of rheumatoid arthritis and psoriatic arthritis (PsA).

Etanercept (Enbrel, Erelzi, etanercept-szzs)

Etanercept consists of a fusion protein of the extracellular portion of the p75 TNF-α receptor and the Fc portion of immunoglobulin G (IgG). It inhibits TNF-α, reducing inflammation and symptoms of ankylosing spondylitis. It is given as a subcutaneous (SC) injection and is available in a prefilled syringe, an autoinjector, or lyophilized powder. It is also approved for rheumatoid arthritis, PsA, psoriasis, and juvenile idiopathic arthritis.

Infliximab (Remicade, Inflectra, infliximab-dyyb, Renflexis, infliximab-abda, Ixifi, infliximab-qbtx)

Infliximab is a chimeric IgG1κ monoclonal antibody (mAb) directed against TNF-α. The variable regions of heavy and light chains are murine in origin, and the constant regions are human. Infliximab inhibits TNF-α, reducing inflammation and symptoms of AS. It is given as an intravenous (IV) infusion. It is also approved for rheumatoid arthritis, PsA, psoriasis, and Crohn disease.

Adalimumab (Humira, Cyltezo Amjevita, adalimumab-atto)

Adalimumab is a human IgG1κ mAb directed against TNF-α. It inhibits TNF-α, reducing inflammation and symptoms of AS. It is given as an SC injection and is available in a prefilled syringe or an autoinjector. It is also approved for rheumatoid arthritis, PsA, psoriasis, juvenile idiopathic arthritis, and Crohn disease.

Golimumab (Simponi)

Golimumab is a human IgG1κ mAb directed against TNF-α. It inhibits TNF-α, reducing inflammation and symptoms of AS. It is given as an SC injection and is available in a prefilled syringe or an autoinjector. It is also approved for rheumatoid arthritis and PsA.

Certolizumab pegol (Cimzia)

Certolizumab pegol is a recombinant humanized anti-human TNF-α neutralizing antibody. It inhibits TNF-α, reducing inflammation and symptoms of ankylosing spondylitis. It is given as a subcutaneous injection and is available as a powder for injection. It is FDA-approved for active ankylosing spondylitis, and is also indicated for Crohn Disease, rheumatoid arthritis, and psoriatic arthritis.

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Immunosuppressants

Class Summary

Immunosuppressants inhibit key factors in the immune system that are responsible for inflammatory responses.

Methotrexate (Trexall, Otrexup, Rasuvo)

Methotrexate has an unknown mechanism of action in AS; it may affect immune function. Effects are observed in the 3-6 weeks following administration. Methotrexate ameliorates symptoms (eg, pain, swelling, stiffness), but there is no evidence that it induces remission. Adjust the dose gradually to obtain a satisfactory response.

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Interleukin Inhibitors

Class Summary

Various interleukins play a role in inflammatory processes.

Secukinumab (Cosentyx)

Human IgG1 monoclonal antibody that selectively binds to and neutralizes the proinflammatory cytokine interleukin 17A (IL-17A). IL-17A is a naturally occurring cytokine that is involved in normal inflammatory and immune responses. It is indicated for adults with active ankylosing spondylitis.

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