How is Ankylosing Spondylitis Treated?

The goals of therapy for AS are to control inflammation, decrease pain, maintain function, and prevent deformity with the least in the way of toxicity.  A therapeutic program will include non-drug and drug components.

What are Non-drug Therapies for Ankylosing Spondylitis?

Maintenance of maximum motion of the skeleton, particularly of the entire spine, is a main focus of non-drug therapy for AS.  Physical therapy with instruction to do range of motion exercises to maintain function is essential to have a good outcome.  Supervised exercises are better than unsupervised exercises in improving pain, stiffness, spinal mobility, and overall well-being in AS patients.  In addition, aerobic conditioning activities, such as a stationary bicycle, or walking program, are helpful in maintain respiratory function and cardiovascular health.

Patient education from health professionals and reliable on-line sources can reinforce important messages involving posture, proper lifting techniques, avoidance of thick sleeping pillows, and the importance of consistent exercise.  The correct balance between exercise and rest can be emphasized.  Rigorous exercise can exacerbate symptoms.   Education about proper nutrition to obtain an ideal weight to minimize stress on weight-bearing joints is also important  for an ideal outcome.

Psychological support may be needed for those young patients who realize they have a chronic illness.  Some patients believe they are disabled before significant disease manifestations have appeared.  Pain, fatigue, joint stiffness can have detrimental effects on interpersonal relationships and work.  Learning coping skills are essential to maintain activities of daily living in its many forms.

What are Drug Therapies for Ankylosing Spondylitis?

A wide variety of drug therapies are available for the treatment of AS.    The key to success is matching the degree of illness with the corresponding drug.  Why not treat AS patients with all the drug categories?  Each drug category has associated side effects.  A patient wants to limit those exposures to a minimum.  Essentially, patients want to take the appropriate number of medicines and not one extra.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs, or aspirin-like drugs possess abilities to decrease pain, fever, and inflammation.  They are anti-inflammatory and pain-relieving when given in larger doses long term.  In AS, NSAIDs decrease spine stiffness and pain.  In a significant number of AS patients, NSAIDs are adequate by themselves to control disease symptoms and improve function.  There is also clinical evidence that NSAIDs may slow the calcification of spine structures when taken on a chronic basis.  A specific type of NSAIDs is cyclo-oxygenase-2 inhibitors.  Cyclo-oxygenase -2 enzyme produces cell messengers (cytokines) that initiate and sustain inflammation in tissues. COX-2 inhibitors prevent the production of these cytokines while having no effect on the products of COX-1 enzyme that is necessary for the normal function of the stomach and kidney.

Muscle Relaxants

Spasms in spinal muscles in AS patients cause pain and limitation of motion.  The addition of a muscle relaxant to a NSAID helps decrease muscle pain and tightness.  The most common side effect of muscle relaxants is sleepiness.  Taking the medicine early in the evening can minimize the possibility of tiredness.

Disease-Modifying Agents (DMARDs)

DMARDs are drugs that work more slowly than NSAIDs but have the capability of modifying the progression of disease.  These drugs have greater benefit in rheumatoid arthritis.  DMARDs do not have a beneficial effect on spinal disease.  Some benefit may exist for arthritis of peripheral joints like the shoulders and hips.  Examples of DMARDs include sulfasalazine, methotrexate, and leflunomide.

Anti-Tumor Necrosis Factor Inhibitors (TNFi)

Cell messengers, or cytokines, are released by cells to initiate a variety of functions.  An inflammatory cytokine, TNF is associated with the clinical manifestations of AS.  TNF is associated with fatigue, joint swelling, stiffness, and pain.  A decrease in the production of TNF, or removal from the blood stream can result in a decrease in disease-associated complaints.  However, the total removal of TNF can be associated with an increased risk of infection.  The goal of therapy is to obtain a physiologic level of TNF.  ANTI-TNF therapies available for the treatment of AS include etarnercept, adalimumab, golimumab,  certolizumab, and infliximab.

The efficacy of the TNF therapies shows no benefit of one agent compared to another.  The use of specific agents in individuals is based on personal preference related to injections versus infusion and frequency of dosing.

Toxicities associated with the use of TNF inhibitors include the activation of latent tuberculosis and increased risk of viral and bacterial infections.  If infections occur, the infection is treated and the TNF therapy stopped until the infection is resolved.  An increased risk of malignancy has been reported.  However, the degree of this increase which is reported to be small is undergoing active evaluation.

What are Surgical Therapies for Ankylosing Spondylitis?

Surgical therapies for AS are more commonly used for the peripheral joints than for the spine.  At times the spine can become so brittles that it will fracture.  The neck is the most common location for this fracture.  Stabilization of the spine is necessary to prevent damage to the spinal cord.

Peripheral joints can be damaged to the degree of requiring a replacement.  The hips and shoulders are the most commonly affected peripheral joints.  The decision about joint replacement must be done in the setting of spine involvement and how the replacement will result in improved function.