PHYSICIAN VOICES

Treatment Options for Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a progressive inflammatory disease that affects vertebrae in the spine and often the hip, knee, and shoulder joints. It can also lead to other issues such as uveitis (eye inflammation) and inflammatory bowel disease (IBD). Although AS is a chronic condition, the good news is that there are many options available to treat the disease and help patients live full, active lives.

Daily NSAIDs are the first line of treatment to reduce inflammation, pain, and stiffness.  NSAIDs, such as ibuprofen (Advil, Motrin) and certain doses of naproxen (Aleve) and the topical gel form of diclonefac (Volatren) are available over the counter. A stronger version of NSAIDs such as celecoxib (Celebrex) is available by prescription. For some patients, taking NSAIDs can be a very effective therapy, in addition to daily exercise. But, not all patients respond to these medications, and some can’t take them due to stomach distress or other side effects, so be sure you discuss this with your healthcare provider.

Many of my patients underestimate the importance of physical therapy and daily exercise. I always try to emphasize how important exercise and physical therapy sessions are when it comes to increasing flexibility and mobility, reducing pain, and improving overall health. Cardiovascular exercise and strength training can help patients achieve a healthy weight while building lean muscle. This combination helps relieve stress and pressure on your joints, reducing inflammation that can lead to AS.

Some patients experience less spine inflammation and instead suffer more from secondary ankylosing spondylitis symptoms like arthritis of the hip, knee, or shoulder. For these patients, I prescribe DMARDs, a class of drugs that reduce inflammation and prevent or reduce joint pain and damage. These drugs work by halting the immune system’s attack, or inflammatory response, on the joints The DMARD I typically prescribe is sulfasalazine (Azulfidine). Methotrexate (Rheumatrex) is another DMARD option for treating AS, although there is much less data regarding its effectiveness to support its use as first-line therapy.

When NSAIDs and DMARDs are not effective or strong enough to relieve the pain, I may inject a corticosteroid shot directly into the inflamed joint. These types of shots can quickly reduce inflammation and, most importantly, provide pain relief. A shot directly into the sacroiliac (SI) joint (the joint that connects the base of your spine to your pelvis) can ease pain and stiffness quickly. While these types of shots can provide fast relief, they are not used as a long-term solution because of the potential for adverse side effects, such as high blood pressure, cataracts, and osteoporosis.

Biological agents, or biologics, are a type of drug that doctors use to treat spinal inflammation, secondary joint inflammation and associated conditions, such as Crohn’s disease, an inflammatory bowel disease. These medications work by suppressing the immune system to block the production of proteins in the body that cause inflammation. One type of biologic is called a TNF inhibitor because it blocks a protein called tumor necrosis factor (TNF). The drugs in this class are administered by injection or by intravenous infusion (IV). The five TNF inhibitor medications approved by the U.S. Food and Drug Administration (FDA) to treat AS are:

• Etanercept (Enbrel)
  
• Infliximab (Remicade)
  
• Adalimumab (Humira)
  
• Golimumab (Simponi)
  
• Certolizumab pegol (Cimzia)
  

In addition to TNF inhibitors, the FDA approved a new class of biologic drugs in January 2016 to treat ankylosing spondylitis. It blocks interleukin (IL) 17, also a protein in the body that causes inflammation (like TNF). Secukinumab (Cosentyx), the first IL-17 inhibitor available, is a good alternative for patients who don’t respond to TNF inhibitors. It’s also administered by injection.
While these drugs are very effective at treating AS, they do come with side effects that require close monitoring. Because they work by suppressing the immune system, infections are a potential side effect, especially tuberculosis. Increased risk for certain cancers is also a rare but serious side effect.

Janus Kinase (JAK) inhibitors have become an available option for AS, especially for patients that have taken NSAID or anti-TNF therapy and symptoms have not improved. The two JAK kinase inhibitors currently approved for AS include tofacitinib (Xeljanz) and upadacitinib (Rinvoq).

Always speak with your doctor before starting a new medication or fitness routine. Different drugs in the same class will have varying levels of effectiveness on different symptoms, so you may end up trying more than one or a combination of two or more. Most DMARDs and biologics take about three months to start working, so it’s important to stay patient and keep in contact with your doctor, especially if you experience any side effects.

Only severe cases of AS may require surgery. On occasion, joint replacement surgery is necessary to replace a severely damaged knee or hip joint. Complex spinal surgery to straighten the spine is considered when the neck vertebrae are fused together in a way that makes it difficult to lift your head, breathe, or move. This surgery is considered high risk and should be performed only by an experienced surgeon.

AS can affect different people in a variety of ways. Fortunately, there is an array of options available to treat all the variations of symptoms. All of the medications used to treat AS, including the different NSAIDs, DMARDs, and biologics, work slightly differently so if one does not relieve symptoms, another one or combination of two or more can help. It’s important to speak with your doctor regularly to make sure your treatment plan is working to minimize your symptoms and prevent the disease from progressing.