Understanding your treatment options: from NSAIDs to biologics

When I was first diagnosed, I spent about three weeks trying to understand what the treatment options for AS were. The information exists, but it is scattered across rheumatology guidelines, patient forums, and drug company websites — none of which speak quite the same language as each other or as me.

This is my attempt to pull it together into something a normal person can actually follow.

Step 1: NSAIDs

NSAIDs — Non-Steroidal Anti-Inflammatory Drugs — are the starting point for almost everyone with AS. You have probably already tried some of these: naproxen (sold as Aleve or Naprosyn), ibuprofen, diclofenac (Voltaren), or celecoxib (Celebrex).

They work by reducing inflammation. For AS specifically, there is evidence that continuous NSAID use — not just taking them when you hurt, but taking them regularly — may also slow the bone-forming process that causes spinal fusion over time. This is a meaningful reason to be consistent with them.

The common experience: NSAIDs take the edge off. Most people find they get partial relief but not complete relief. If your pain goes from an 8 to a 4, that is a meaningful response. If they do nothing at all after a full trial, that is also information.

Which NSAID to try

Naproxen is usually first because it is cheap, widely available, and relatively well-tolerated. Diclofenac is often felt to be more effective for AS-type inflammation — many patients describe it as the strongest of the standard NSAIDs. Celecoxib (a COX-2 inhibitor) is gentler on the stomach and preferred for people with GI sensitivities, though some find it less potent.

Most people cycle through 2-3 NSAIDs before finding one they can sustain. If one does not work after 4-6 weeks at maximum dose, try another — they have different mechanisms and one may work better for you than another.

Long-term NSAID use: what to watch for

Long-term NSAIDs carry real risks: stomach lining damage, kidney stress, and blood pressure effects. Most rheumatologists will prescribe a PPI (proton pump inhibitor, like omeprazole) alongside to protect the stomach. Regular kidney function monitoring is sensible with prolonged use. These are manageable risks, but they require monitoring — not something to ignore.

Step 2: Biologics

Biologics are the next step when NSAIDs do not provide sufficient relief. They are injectable or infused medications that target specific proteins in the immune system responsible for the inflammation in AS.

They are not the same as painkillers or conventional anti-inflammatory drugs. They intervene upstream in the inflammatory process rather than managing the symptoms at the end of the chain.

TNF inhibitors — the first generation

TNF (tumour necrosis factor) is one of the key inflammatory proteins in AS. Blocking it with a TNF inhibitor has been the standard biologic approach for two decades.

The main ones used in AS: adalimumab (Humira), etanercept (Enbrel), certolizumab (Cimzia), golimumab (Simponi), and infliximab (Remicade). They all work on the same principle but have different dosing schedules — some are every-2-weeks self-injections, some are monthly, infliximab is an IV infusion every 6-8 weeks.

When they work, the results can be dramatic. 'I got my life back' is a phrase that comes up repeatedly in AS communities after starting biologics. Response rates are around 50-60% achieving significant improvement in the first 3 months.

When they don't work: about 30-40% of people do not respond adequately to the first biologic. Switching to a different TNF inhibitor, or switching to a different class entirely, often helps.

IL-17 inhibitors — the newer option

Secukinumab (Cosentyx) and ixekizumab (Taltz) target IL-17, a different inflammatory protein. They are equally effective to TNF inhibitors for most people, and they are an important alternative for people who do not respond to TNF inhibitors or cannot use them.

The choice between TNF inhibitors and IL-17 inhibitors is not always clinically obvious — your rheumatologist will factor in any other conditions you have (IL-17 inhibitors are not used in IBD, for example), your lifestyle (injection frequency), and sometimes your insurance formulary.

JAK inhibitors — the newest class

Tofacitinib (Xeljanz) and upadacitinib (Rinvoq) are JAK inhibitors — oral tablets rather than injections. They are used when biologics have failed. They are highly effective but have a more significant side effect profile, and regulatory cautions around cardiovascular and cancer risk mean they are typically reserved for people who have not responded adequately to biologics.

How to know if your treatment is working

Your rheumatologist will use scoring tools — BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and ASDAS (Ankylosing Spondylitis Disease Activity Score) are the main ones. These are questionnaires about your symptoms combined with blood markers.

But the most important question is simpler: is your life meaningfully better? Can you do things you could not do before? Is your morning stiffness shorter? Can you sleep more nights than not?

Blood markers (CRP, ESR) matter, but not all AS patients have elevated markers even with active disease. 'Normal bloods' does not mean you are well-controlled if you are still in significant pain.

The insurance fight (mainly US, but relevant elsewhere)

In the United States and some other countries, accessing biologics often involves an insurance fight. Prior authorisation requirements, step therapy ('you must try and fail X drug before we will approve Y'), and appeals when coverage is denied are common experiences.

A few things that help: your rheumatologist's office has usually dealt with this before and knows the required documentation. Patient assistance programmes exist for most major biologics — if you cannot afford the cost-sharing, these programmes can significantly reduce out-of-pocket costs. Organisations like the Spondylitis Association of America have resources specifically about insurance navigation.

The fight is real and it is exhausting. But it is usually winnable.