What is best for severe axial disease in Ankylosing Spondylitis?

• A. NSAIDs
• B. Steroids
• C. Methotrexate
• D. TNF inhibitors

Answer: (D)

Inflammation driving the spine is the main issue in severe axial disease of Ankylosing Spondylitis, so therapy that targets this inflammation directly is most effective. NSAIDs help with pain and stiffness and are usually tried first, but when axial symptoms remain active despite NSAIDs, a treatment that blocks a key inflammatory cytokine is preferred. Steroids are not effective for axial inflammation when given systemically, and methotrexate has limited impact on spine-related symptoms. TNF inhibitors specifically suppress the inflammatory signals fueling spinal disease and have robust, well-established evidence showing significant improvements in back pain, morning stiffness, and function for patients with severe axial AS. Therefore, TNF inhibitors are the best option in this scenario.