The purpose of this study is to compare disease severity in ankylosing spondylitis (AS) in three ethnic groups. We assessed 925 AS patients (57 Blacks, 805 Whites, 63 Latinos) enrolled in the longitudinal Prospective Study of Outcomes in AS (PSOAS) for functional impairment, disease activity, and radiographic severity. Comparisons of clinical characteristics and HLA-B27 frequency for each group were performed, in two multivariable regression models, we compared the baseline Bath Ankylosing Spondylitis Radiographic Index (BASRI) and modified Stokes Ankylosing Spondylitis Spine Score (mSASSS) by ethnicity, adjusting for covariates. Blacks had greater functional impairment (Bath Ankylosing Spondylitis Functional Index) (median 62.5 vs. 27.8 in Whites and 38.1 in Latinos;
p < 0.0001); higher disease activity (Bath Ankylosing Spondylitis Disease Activity Index), (median 5.9 vs. 3.5 in Whites and 4.5 in Latinos;
p < 0.0001), erythrocyte sedimentation rate (median 27.0 in Blacks vs. 10.0 in Whites and 17.0;
p < 0.0001), and C-reactive protein levels (median 1.2 vs. 0.4 mg/dL in Whites and 0.9 in Latinos;
p < 0.0001). Baseline BASRI and mSASSS were higher in Blacks (mean 9.5 and median 38.2, respectively) compared to Whites (7.3 and 6.4) and Latinos (7.3 and 8.1), (
p = 0.004, 0.007), respectively, more significant as disease duration increased. HLA-B27 occurred in 62.5% of Blacks, 85.3% of Whites, and 86.7% of Latinos (
p < 0.0001). On multivariable analysis, higher BASRI and mSASSS were associated with Black ethnicity, after adjusting for disease duration and gender as well as TNF inhibitor (TNFi) usage, smoking status, or education level. Blacks with AS have more severe disease compared to either Whites or Latinos.