Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis

Abstract

Objective: To assess available management strategies in ankylosing spondylitis (AS) using a systematic approach, as a part of the development of evidence based recommendations for the management of AS. Methods: A systematic search of Medline, Embase, CINAHL, PEDro, and the Cochrane Library was performed to identify relevant interventions for the management of AS. Evidence for each intervention was categorised by study type, and outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated for each intervention where possible. Results from randomised controlled trials were pooled where appropriate. Results: Both pharmacological and non-pharmacological interventions considered to be of interest to clinicians involved in the management of AS were identified. Good evidence (level Ib) exists supporting the use of non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs for symptomatic treatment. Nonpharmacological treatments are also supported for maintaining function in AS. The use of conventional antirheumatoid arthritis drugs is not well supported by high level research evidence. Tumour necrosis factor inhibitors (infliximab and etanercept) have level Ib evidence supporting large treatment effects for spinal pain and function in AS over at least 6 months. Level IV evidence supports surgical interventions in specific patients. Conclusion: This extensive literature review forms the evidence base considered in the development of the new ASAS/EULAR recommendations for the management of AS.A nkylosing spondylitis (AS) is a chronic inflammatory rheumatic disease most commonly affecting the axial skeleton, which historically has been difficult to treat. Recent years have seen the introduction of exciting new therapeutic strategies, particularly the tumour necrosis factor inhibitors. Therefore it is important that clinicians are aware of the relative benefits and risks of the different treatments available to them, and have evidence based information about which strategies are the most efficacious in particular patient settings.The ASsessment in AS (ASAS) International Working Group, in collaboration with the European League Against Rheumatism (EULAR), recently developed evidence based recommendations for the management of AS 1 to assist all health professionals involved in the care of patients with AS.The recommendations were developed using information from two major sources: a systematic review of the literature, and expert opinion based on the research evidence and clinical expertise.1 This review details the literature search performed and the results presented to the expert committee for the purpose of developing recommendations for the management of AS. METHODSA systematic search of the literature published between January 1966 and December 2004 was undertaken using Medline, Embase, CINHAL, PEDro, and Cochrane Library databases. The search included both a general search and an interve...

Dietary manipulation in musculoskeletal conditions

“…Bowel microbes depend on dietary starch for growth, thus a reduction in consumption of starchy foods has been proposed [21]. Existing evidence does not support the use of this dietary regime in routine practice [22].…”

A 2-year comparative open label randomized study of efficacy and safety of etanercept and infliximab in patients with ankylosing spondylitis

“…Therapeutic options for AS, such as non-steroidal anti-inXammatory drugs (NSAIDs), oVer temporary pain relief with little if any clinical beneWt on spinal mobility, and disease modifying antirheumatic drugs (DMARDs) do not appear to aVect the spinal involvement of AS [2].…”

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“…Their efficacy has been confirmed by a wide number of experimental and clinical studies (Kean & Buchanan 2005, Zochling et al 2006, Ong et al 2007). Despite their efficacy, the use of NSAIDs induces serious adverse effects when administrated chronically, with the gastrointestinal tract being the most affected system (Ofman et al 2002).…”