Ankylosing spondylitis (AS) is treated with a combination of anti-inflammatory medications, regular exercise, and in some cases biologic drugs that target specific parts of the immune system. There is no cure, but most people can manage pain, preserve spinal mobility, and slow the progression of joint damage with the right treatment plan. What works best depends on how active your disease is and how well you respond to initial therapies.
Anti-Inflammatory Medications Come First
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the starting point for nearly everyone with AS. These include both over-the-counter options like ibuprofen and naproxen, and prescription-strength versions like meloxicam, piroxicam, and celecoxib. In clinical trials, meloxicam at 15 mg daily and piroxicam at 20 mg daily both showed clear benefits over placebo for pain and stiffness.
One question that comes up often is whether you should take NSAIDs every day or only when symptoms flare. Taking them continuously can make it easier to stay active and keep up with exercise, and there’s some evidence it may even slow structural damage to the spine. On the other hand, daily use raises the risk of stomach, kidney, and cardiovascular side effects over time. Your doctor will help you weigh those trade-offs based on your symptom pattern. Many people start with continuous daily dosing and then shift to as-needed use once their symptoms stabilize.
Biologic Therapies for Moderate to Severe Disease
If NSAIDs don’t control your symptoms after several weeks, the next step is usually a biologic medication. These are injected or infused drugs that block specific immune proteins driving inflammation. The most established class targets a protein called tumor necrosis factor (TNF), which plays a central role in the inflammatory process that damages spinal joints.
Several TNF inhibitors are approved for AS: adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), certolizumab pegol (Cimzia), and golimumab (Simponi). Biosimilar versions of adalimumab and infliximab are also available, often at lower cost. Most people notice significant improvement within the first few months. These drugs are given as self-injections every one to two weeks or as infusions at a clinic every several weeks, depending on the specific medication.
For people who don’t respond well to TNF inhibitors, a newer class of biologics targets a different immune protein called IL-17A. Secukinumab and ixekizumab both selectively block IL-17A, which is a key driver of inflammation in AS. Bimekizumab takes a slightly different approach by blocking both IL-17A and a related protein, IL-17F. These drugs offer an important alternative when TNF inhibitors haven’t worked or have caused side effects.
Oral Targeted Therapies
A newer category of treatment uses pills rather than injections. JAK inhibitors, including upadacitinib, work by blocking signals inside immune cells that promote inflammation. These are typically reserved for people who haven’t responded adequately to biologics or who prefer an oral medication. They carry their own set of risks, so the decision to use them involves careful discussion about your overall health profile.
Exercise and Physical Therapy
Medication manages inflammation, but exercise is what keeps your spine flexible and your posture upright. This isn’t optional or supplementary. Regular physical activity is one of the most effective tools you have, and skipping it accelerates the stiffness and postural changes that AS can cause over time.
A physical therapist experienced with AS will typically focus on three areas. Strengthening exercises for your back and core muscles reduce pain and improve your ability to walk and carry out daily activities. Flexibility and range-of-motion work keeps your spine and other joints from stiffening, which is especially important in the morning when AS stiffness tends to peak. Posture training helps counteract the forward curvature that can develop as the disease progresses.
Swimming, water aerobics, yoga, and cycling are all popular choices because they build strength and flexibility without high impact on the joints. The key is consistency. Even 20 to 30 minutes a day of targeted stretching and strengthening makes a measurable difference in how your spine moves and how much pain you experience. Many people find that exercising first thing in the morning, right after a warm shower, is the most effective way to work through morning stiffness.
Diet and Inflammation
No specific diet has been proven to treat AS on its own, but there is growing evidence that what you eat can influence disease activity. A systematic review of dietary research in spondyloarthritis found that adherence to a Mediterranean diet was associated with meaningful improvement in disease activity scores. The Mediterranean diet emphasizes fruits, vegetables, whole grains, fish, olive oil, and nuts while limiting processed foods, red meat, and refined sugars.
The mechanism likely comes down to reducing overall inflammation in the body. Processed foods, excess sugar, and alcohol tend to promote inflammation, while the fats found in fish, nuts, and olive oil have anti-inflammatory effects. Adopting this eating pattern won’t replace your medications, but it can complement them and may help you feel better overall.
Tracking Your Disease Activity
AS treatment isn’t static. Your doctor will periodically assess how active your disease is using standardized scoring tools. The most widely used is the ASDAS (Ankylosing Spondylitis Disease Activity Score), which combines your reported symptoms with a blood marker of inflammation into a single number.
The thresholds that guide treatment decisions are straightforward: a score below 1.3 means inactive disease, between 1.3 and 2.1 is low disease activity, between 2.1 and 3.5 is high disease activity, and above 3.5 is very high disease activity. The goal of treatment is to get you below 2.1, and ideally below 1.3. If your score stays high despite your current regimen, that’s the signal to consider switching or adding medications.
When Surgery Becomes Necessary
Most people with AS never need surgery, but it becomes an option when the disease causes severe structural changes that medications and exercise can’t address. The two main surgical scenarios are spinal deformity and hip damage.
Spinal osteotomy is a procedure where a surgeon cuts and repositions sections of the spine to correct severe forward curvature. This is considered when kyphotic deformity becomes so pronounced that it affects your ability to look straight ahead, a problem sometimes described as “chin-on-chest” deformity. Surgeons use a measurement called the chin-brow-to-vertical angle to plan these corrections, and restoring the ability to gaze horizontally is the primary goal. The surgery is complex but can dramatically improve quality of life for people with advanced deformity.
Hip replacement is the other common surgical intervention. AS frequently affects the hip joints, and when arthritis there becomes severe enough to limit walking or cause constant pain, total hip replacement provides reliable relief. Some people need both hips replaced, particularly when hip stiffness itself contributes to a forward-stooped posture.