PENATALAKSANAAN

At this time, there is no known curative treatment for ankylosing

spondylitis. Goals of treatment are to reduce pain and stiffness, slow
progression of the disease, prevent deformity, maintain posture, and
preserve function. Physical therapy, exercise, and medications are the
main forms of treatment. There are rare opportunities for surgical
intervention.

Lifestyle Modification
Physical therapy and exercise regimens are prescribed for all patients with
ankylosing spondylitis. This has been shown to improve measures of pain,
spinal mobility, patient functioning, and well-being. Supervised programs
have been found to be better than at-home versions.23 Patient education
programs can increase understanding and compliance. Cigarette smoking
has been associated with a poor functional outcome,24 and patients should
be encouraged to quit.

Medical Options
Nonsteroidal anti-inflammatory drugs (NSAIDs) should be prescribed for all
patients unless contraindicated. They appear to provide benefits in both
pain and function. Generally, regardless of the NSAID used, the maximum
approved dosage is required for efficacy. In a pooled analysis of NSAIDs
versus placebo over 6 weeks, NSAIDs significantly improved spinal pain,
peripheral joint pain, and function. Cyclooxygenase-2 inhibitors were
equally effective, although effect on peripheral arthritis was not
investigated.25 Their disease-modifying properties remain unclear. Possible
radiographic slowing has been demonstrated with continuous versus ondemand use.26 Side effects are common, typically mild, and mainly
gastrointestinal. Rarely, there can be more significant gastrointestinal,
renal, hepatic, and cardiovascular toxicities.
Systemic corticosteroids are typically not necessary and have only a
limited role. However, injectable steroid preparations can be used for
enthesitis and peripheral arthritis. Injection of long-acting steroids into the
sacroiliac joints has been found to be beneficial in some.27
The use of disease-modifying antirheumatic drugs (DMARDs) has been
adapted mainly from use in rheumatoid arthritis. Several agents have
been employed, including gold salts, methotrexate, sulfasalazine,
hydroxychloroquine, and leflunomide.
In a Cochrane meta-analysis of 11 randomized, controlled trials,
sulfasalazine demonstrated some benefit in reducing ESR, morning
stiffness and peripheral arthritis (two trials) and no benefit in improving
physical function, pain, spinal mobility, enthesitis, or patient and physician
global assessment.28 Patients with early disease, elevated ESR, and
peripheral arthritis might benefit from a trial of sulfasalazine. Side effects
are typically dose related, mild, and mainly gastrointestinal. Rarely there
are more serious allergic, hematologic, and renal toxicities.
A similar meta-analysis of two trials with methotrexate versus naproxen
demonstrated no difference in outcomes of pain, function, peripheral
arthritis, enthesitis, morning stiffness, patient and physician global

assessement, ESR, or CRP.29 Additional randomized, controlled studies with

higher dosages for longer periods of time are necessary.
Four antiTNF- agents in the United States (infliximab, golimumab,
etanercept, and adalimumab) have been evaluated and approved by the
U.S. Food and Drug Administration (FDA) for use in ankylosing spondylitis.
80% of patients respond to at least one of the agents, and the response is
typically rapid and sustainable.30 The larger clinical trials data for all four
drugs demonstrate relatively similar results. Using standard clinical
assessment tools, 50% to 60% of patients achieved more than 20%
clinical trial response (Ankylosing Spondylitis Assessment Study Group
[ASAS 20]) at 24 weeks.31, 32, 33, 41 Observational studies have demonstrated
continued response at 2 years.34, 35 In a pooled analysis of six of the
studies, TNF antagonists have demonstrated moderate to large effects on
spinal pain, peripheral joint pain, and function.25 Lack of response to one of
the agents does not predict response to another. Predictors of positive
response include shorter disease duration, better functional index, higher
disease activity, and higher CRP.36 These drugs are not available in oral
form and are quite expensive. Side effects include infections (re-activation
of latent tuberculosis or fungi), demyelination, and injection or infusion
reactions. The disease-modifying capabilities of these agents are still
being assessed. In infliximab-treated patients, the MRI activity score was
significantly reduced.37 However, in another study, radiographic
progression continued, but at a slower rate than in traditional cohorts.38

Surgical Options
Total hip replacement is the most common surgery performed in patients
with ankylosing spondylitis.39, 40 Revision surgery may be necessary,
because these patients typically present at a young age and when they
are still active. Heterotopic ossification following joint replacement is a
well-described but still unusual complication following hip replacement.
Cervical fusion is indicated for the rare patient with neurologic
complications of atlantoaxial subluxation. This is managed similarly to
rheumatoid arthritis.
Ultimately, each patients treatment must be individualized.
Considerations must be made for the level of disease activity, degree of
functional impairment, concomitant illnesses, tolerance of medications,
and patient and physician expectations
Matthew P. Bunyard
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/r
heumatology/ankylosing-spondylitis/
Ten main recommendations for the management of ankylosing spondylitis
have been proposed by a combined ASsessment in Ankylosing Spondylitis
working group (ASAS) and European League Against Rheumatism (EULAR)
task force (figure 4).98 Briefly, the treatment of ankylosing spondylitis
should be tailored according to the manifestations of the disease at
presentation, severity of symptoms, and several other features that
include the wishes and expectations of the patient. The disease
monitoring of patients should include history, clinical features, laboratory
tests, and imaging. The frequency of monitoring should be decided on an

individual basis depending on symptoms, severity, and drugs. The best

treatment needs a combination of non-pharmacological
and pharmacological treatment methods, including edu- cation and
physical therapy. AntiTNF therapy should be given according to ASAS
recommendations.99 Joint replacement has to be considered in patients
with radio- graphic evidence of advanced hip involvement who have
refractory pain and disability. Spinal surgery is useful in selected patients
with symptoms and disability because of disabilitating posture or instable
spine.

Basic principles of treatment

The standard treatment of spinal symptoms for patients with ankylosing
spondylitis has consisted of NSAIDs100and structured exercise
programmes101 for decades. Whether and to what extent physical therapy
and exercise are beneficial in every stage of the disease (eg, in very
active disease) is unknown. Disease activity, especially the degree of
spinal inflammation, function, and damage, probably affects the outcome
of physical therapy and regular exercise. Non-pharmacological therapy
consists of spa treatment,102 education, and self-help groups, as well as
physical therapy. A Cochrane review103 showed that there is little evidence
for effectiveness of non-pharmacological intervention, but there is strongly
positive expert opinion. Although the general effect size is believed to be
rather small, it is clear from clinical experience that individual patients
with ankylosing spondylitis may have definite benefit from intensive
physiotherapy. Intensive spa therapy has proved more effective than
standard prescriptions of exercises in an outpatient setting, especially
after several months.
Jrgen Braun, Joachim Sieper, Ankylosing spondylitis,Lancet 2007; 369:
137990
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