308Arthritis Research Vol 4 No 5 Braun and Sieper and sex-matched AS patients with severe disease were compared with RA patients with severe disease, the grades of pain and disability were similar [5]. Furthermore, absence from work and work disability is clearly greater in patients with AS than in individuals without the disease [6][7][8]. In a recent survey in the USA [9], the most prevalent quality-of-life concerns of patients with AS included stiffness (90.2%), pain (83.1%), fatigue (62.4%), poor sleep (54.1%), concerns about appearance (50.6%), worry about the future (50.3%) and side effects of medication (41%). Indeed, fatigue has been identified as a major problem in AS -closely associated with pain and stiffness [10]. However, many AS patients cope better with their disease than RA patients, possibly because of the earlier onset of AS and the somewhat better education in AS patients. In recent decades, patients, general practitioners and rheumatologists have arranged themselves a lot with the situation in AS, because that is what happens when there is no treatment available.Thus, SpA in general and AS especially are more prevalent than was previously thought and have a clear socioeconomic impact on society. Against this background, it is becoming increasingly clear that more effective therapies are needed. Although there is a role for intensive physiotherapy, as was recently shown [11,12], this review concentrates on the drug therapy of AS -the most prevalent subtype of SpA, and the one with the most severe outcome.
Treatment of ankylosing spondylitis with nonsteroidal anti-inflammatory drugsNonsteroidal anti-inflammatory drugs (NSAIDs) and intraarticular coriticosteroids are accepted, often-used treatments for AS [13]. NSAIDs are taken, with varying efficacy, by about 70-80% of AS patients. A good response to NSAID treatment has even been suggested as a criterion for the diagnosis of inflammatory back pain and SpA [14]. A poor response or none to NSAIDs has been identified as a poor prognostic sign in AS [15,16]. Patients' responses to NSAIDs are broadly similar but nevertheless often differ markedly from one person to another. Several NSAIDs may therefore need to be tried to identify the best one for a particular patient, and high doses are often required in severe cases [16]. Indomethacin, naproxen and diclofenac are among those most frequently used in AS, but others clearly work also [17]. Finally, an almost historical but very effective agent, phenylbutazone (not available in the USA), may be tried by experienced rheumatologists for patients with severe AS [15,18].There is evidence that the new, more COX-2 selective drugs meloxicam and celecoxib [19,20] are no less effective in treating back pain of AS patients than conventional NSAIDs such as piroxicam and ketoprofen. The effectiveness of these newer drugs may be associated with the advantage of less serious gastrointestinal events.However, as in other rheumatic diseases, NSAIDs are valuable only to improve the symptoms of spinal inflammti...