For axial SpA, treatment starts with NSAIDs at the lowest effective dose for pain. If a DMARD is needed, the patient should be informed about the advantages and disadvantages of each drug before the choice is made. However, if more than one DMARD seems suitable, then the least expensive should be selected.9
Adalimumab, certolizumab pegol, etanercept, golimumab or infliximab are recommended (within their licence and the relevant NICE technical appraisal in relation to cost) as options for severe active ankylosing spondylitis where NSAIDs are insufficiently effective or not tolerated. Adalimumab, certolizumab pegol, and etanercept are also suitable for severe non-radiographic axial SpA.
Response to treatment should be assessed after 12 weeks and only continued if there is a significant and measurable improvement in symptoms. If the patient does not respond to one TNF-α inhibitor, or its effect is declining, an alternative can be tried.
If NSAIDs or TNF-α inhibitor treatment are ineffective, then secukinumab can be considered for ankylosing spondylitis, with assessment after 16 weeks.