OBJECTIVES: To appraise the literature referred to direct and indirect costs of ankylosing spondylitis (AS) in Europe. METHODS: A systematic review of the literature was performed. Electronic databases [MedLine/PubMed, Cochrane Library, ISI Wok, DARE, NHSEED, HTA] and Google Scholar were searched to identify publications regarding direct and indirect costs of AS in Europe. Bibliographic references were hand searched. European studies published in English or Spanish until May 2015 were selected. Editorials, letters, commentaries, opinion papers, congress proceedings and studies related to specific treatments were excluded. Costs were updated to €,2015. RESULTS: Ten studies were reviewed (n=2 systematic reviews, n=1 cost-effectiveness, n=5 cross-sectional and n=2 retrospective observational studies). Half of them (n=5) evaluated AS cost from patient perspective. The main component of the the cost from societal perspective was the indirect cost (53.4%-62%). AS severity increased 2 times the direct cost and 4 times the indirect cost. The total cost increased 18.4 times from BASFI=1 to BASFI=10, and 1.6 times form BASDAI=1 to BASDAI=10. Absenteeism rates varied from 11% to 16%, and presentism from 19% to 33%. Disease activity (OR=3,24; OR=3,97) and depression (OR=3,22; OR=5,69) were predictors of absenteeism and presentism, while anxiety (OR=3,90) and patients’ age (OR=1,04 per year) were associated with presentism. CONCLUSIONS: Although costs estimations related to AS varied across European countries, the results showed that economic burden of AS in Europe is substantial, being the indirect cost due to productivity loss the main components of total cost. Worse physical function and higher disease activity were the main determinants of total costs. Disease activity and depression were associated with absenteeism and presentism.