Beyond pharmacotherapy: a narrative review of patient, social, and healthcare system factors influencing treatment adherence in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease characterized by inflammatory low back pain, new bone formation, and progressive ossification of the axial skeleton. Over time, it causes irreversible structural damage to the spine and sacroiliac joints, profoundly impairing patients' quality of life and physical function. Without timely and effective intervention, AS can lead to permanent functional disability. Evidence suggests that biological, psychological, and social factors jointly undermine treatment adherence, with complex interactions among these dimensions that make single-domain interventions insufficient. Improving adherence to treatment regimens therefore requires a thorough understanding of these multifaceted influences and the development of evidence-based, multicomponent strategies. This narrative review synthesizes literature published from 2010 to 2024, drawn from PubMed/MEDLINE, Embase, Web of Science, the Cochrane Library, and CNKI, to identify factors contributing to non-adherence in AS patients, with particular attention to disease knowledge, perceptions of treatment efficacy, exercise and rehabilitation adherence, and social support. Wherever possible, evidence derived directly from AS or axial spondyloarthritis (axSpA) populations is distinguished from findings extrapolated from broader rheumatology or chronic-disease literature. Based on this synthesis, targeted recommendations for optimizing treatment management and enhancing long-term patient outcomes are proposed, together with priority directions for future AS-specific adherence research.