This article reviews the last decade studies on the economic impact of ankylosing spondylitis (AS). Interestingly, a common observation is that in AS indirect costs are higher than the use of direct healthcare resources. Country, age, gender, and severity of the diseases impact on per patient annual costs AS related. Different payment and reimbursement regimes may impact on the amount and distribution of indirect costs. The differences observed among countries on absolute and relative (compared with direct costs) amounts of indirect costs can be explained with the capability of a country of actually measure productivity losses and indirect costs. Low indirect costs without other indicators should not be considered as a sign of efficiency in AS care, but may be due to an underestimation of AS-related costs; as a consequence, indirect costs may be a net loss for patients that nobody can repay. A private insurance reimbursement regime has the highest capability of inducing players to define, select and actually identify indirect costs better than in different reimbursement regimes. Therefore indirect costs may become very high in case of private insurance regimes because of their more detailed identification.