7 Biologics for Ankylosing Spondylitis: A Pharmacist’s Take on Humira, Cosentyx, and More

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Pain and inflammation in the spine and joints are a couple of symptoms you might experience if you're living with ankylosing spondylitis (AS), a type of autoimmune arthritis. Nonsteroidal anti-inflammatory drugs (NSAIDs) - such as ibuprofen (Advil, Motrin) or celecoxib (Celebrex) - are first-choice treatment options for AS. But sometimes they aren't enough to manage your symptoms on their own.

Just like creating a flavorful dish involves putting together complementary ingredients, sometimes the key to a successful treatment plan is finding the right combination of medications that can work together as a team. That's where biologics come into play. These prescription medications are made from living or natural sources and typically come as injections or intravenous (IV) infusions. Biologics block certain proteins that cause inflammation. In turn, they lower inflammation caused by AS.

Here, we'll highlight seven biologics for AS. Together with your healthcare team, you can determine which one is the best fit for you.

1. Enbrel

Enbrel (etanercept) became the first FDA-approved AS biologic in 2003. It's a tumor necrosis factor (TNF) inhibitor; it blocks TNF proteins to lower inflammation and manage AS symptoms in adults.

The American College of Rheumatology (ACR) recommends starting a TNF inhibitor, such as Enbrel, if NSAIDs alone aren't sufficiently managing your inflammation. Research shows Enbrel is safe and effective for AS over time, even after 5 years of treatment.

Enbrel comes as a subcutaneous (under the skin) injection given once weekly. You can administer it yourself or have a loved one do it for you. Your pharmacist can show you how to administer Enbrel.

Tip: Many people administer Enbrel using an autoinjector pen. If you're using the Enbrel SureClick autoinjector, the window on the pen should turn yellow when the injection is complete. The AutoTouch reusable autoinjector pen button flashes green when you begin the injection, and it turns off after your injection is finished.

2. Humira

Humira (adalimumab) is a popular biologic that treats a variety of autoimmune conditions, including AS. It's another TNF inhibitor that's a go-to biologic for AS in adults. One review of 14 studies found that Humira effectively lowered inflammation, pain, and improved physical mobility over time.

Like Enbrel, you can self administer Humira under the skin. But Humira is given once every other week - less frequently than Enbrel.

3. Remicade

Remicade (infliximab) extends the list of TNF inhibitors approved to treat AS in adults. One feature sets Remicade apart from Enbrel and Humira, though. It's given as an IV infusion in a medical setting.

You'll start out by receiving 3 IV infusions over a 6-week period. These initial doses are known as loading doses. They're meant to get the medication into your body quickly. After this, you'll receive a maintenance infusion once every 6 weeks. Studies show Remicade is effective at managing AS symptoms over time (at least 3 years).

Autoimmune biologics like Remicade may raise your chances of experiencing an infection since they suppress your immune system. This includes a risk of tuberculosis (TB). You should be tested for TB before starting Remicade and during treatment.

Good to know: Do your best to prepare for your Remicade infusions. Each one takes about 2 hours. Drink plenty of fluids and dress comfortably. You may even want to bring a book or mobile device to help you relax and stay occupied.

4. Cimzia

Cimzia (certolizumab pegol) is another approved and ACR-recommended option for managing AS in adults. In one 2-year study, Cimzia improved a variety of AS symptoms, including back pain, fatigue, and overall well-being.

Like the above biologics, Cimzia is a TNF inhibitor. You can conveniently self-administer Cimzia as a subcutaneous injection every 2 to 4 weeks. Overall, its risks and side effects are comparable to other TNF inhibitors.

5. Simponi

Simponi (golimumab) treats conditions such as AS, ulcerative colitis, rheumatoid arthritis, and more. It's the fifth and final TNF inhibitor for AS in adults on this list. In a 2-year study, Simponi improved AS symptoms and overall well-being.

You can self-administer the standard version of Simponi under the skin once a month. But you also have another dosing option. Simponi Aria is an IV infusion that's administered by a healthcare professional in a medical setting. The first 2 infusions are administered 4 weeks (1 month) apart. After this, you receive maintenance infusions once every 8 weeks (2 months).

6. Taltz

Taltz (ixekizumab) belongs to a group of medications called interleukin-17A (IL-17A) blockers. It lowers inflammation by blocking inflammatory IL-17A proteins. Taltz is approved to manage AS symptoms in adults.

Taltz isn't considered a first-choice medication for AS. That's because TNF inhibitors are generally more effective for AS. Your healthcare professional may prescribe Taltz, though, if TNF inhibitors don't work for your symptoms.

That being said, in a 3-year study, Taltz was effective at improving AS symptoms.

Taltz comes as a subcutaneous injection that you can administer yourself. You start out with a loading dose of 2 injections. After this, you administer 1 injection every 4 weeks.

7. Cosentyx

Cosentyx (secukinumab) has some overlap with Taltz. It's an IL-17A blocker approved for AS in adults. A 5-year study found that Cosentyx sustainably improved AS symptoms.

There's some flexibility when it comes to how to use Cosentyx. It's available as a subcutaneous injection that you can self-administer. The maintenance dosage is 1 injection every 4 weeks. Cosentyx also comes as an IV infusion given in a medical setting. You have the option of receiving it with or without a loading dose. The Cosentyx maintenance dosage is 1 infusion every 4 weeks.

What is the best biologic for ankylosing spondylitis?

TNF inhibitors - such as Enbrel, Humira, and Remicade - are typically recommended over other AS biologics. That's because TNF inhibitors currently have the most data showing they're effective for AS.

But TNF inhibitors aren't for everyone. The best biologic for you may depend on other health conditions you may have. If you have heart failure, for example, TNF inhibitors can actually worsen your symptoms. In this case, your healthcare professional may prescribe Taltz or Cosentyx. These aren't expected to impact your heart in the same way.

Convenience could be an important factor in your decision too. If you're looking for a biologic that you can self-administer with relatively infrequently, then Cimzia or Simponi might be the best options. The biologic that's preferred by your insurance plan may be another factor.

What biosimilars are available for ankylosing spondylitis?

Biosimilars are highly similar to their original (reference) biologics. But biosimilars are typically available at a lower cost.

A variety of biosimilars are available for AS. Check out the table below to see which ones have hit the U.S. market.

A couple of Enbrel biosimilars are also approved for AS. But they aren't commercially available yet.

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