Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
What are treatment options for ankylosing
spondylitis?
The treatment of ankylosing spondylitis typically involves
the use of medications to reduce inflammation and/or suppress immunity to stop progression of the disease,
physical therapy, and exercise. Medications decrease inflammation
in the spine and other joints and organs. Physical therapy and
exercise help improve posture, spine mobility, and lung capacity.
Aspirin and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are commonly used to decrease pain and stiffness of the
spine and other joints. Commonly used NSAIDs include indomethacin
(Indocin), tolmetin (Tolectin),
sulindac (Clinoril), naproxen
(Naprosyn), and diclofenac (Voltaren). Their common
side effects include stomach upset, nausea, abdominal pain, diarrhea, and even
bleeding ulcers. These medicines are frequently taken with food
in order to minimize side effects.
In some people with ankylosing spondylitis,
inflammation
of joints excluding the spine (such as the hips, knees, or ankles) becomes the major problem. Inflammation in these joints may not respond to NSAIDs alone.
For these individuals, the addition of medications that suppress the body's immune system
is considered. These medications, such as sulfasalazine (Azulfidine),
may bring about long-term reduction of inflammation. An alternative to sulfasalazine that is somewhat more effective is methotrexate (Rheumatrex, Trexall), which can be administered
orally or by injection. Frequent blood tests are performed during
methotrexate treatment because of its potential for toxicity to
the liver, which can even lead to cirrhosis, and toxicity to bone
marrow, which can lead to severe anemia.
Recent research has shown that for persistent ankylosing spondylitis with spinal involvement that is unresponsive to anti-inflammatory medications, both sulfasalazine and methotrexate are ineffective. Newer, effective medications for spine disease attack a messenger protein of inflammation called tumor necrosis factor
(TNF). These TNF-blocking medications have been shown to be extremely effective for treating ankylosing spondylitis by stopping disease activity, decreasing inflammation, and improving spinal mobility. Examples of these TNF-blockers include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), and golimumab (Simponi).
Several major points about the treatment of ankylosing spondylitis deserve emphasis. There is an early, underdiagnosed stage of
spondylitis that occurs before plain X-ray testing can detect classic changes.
Patients who are treated earlier respond better to treatments. Current
disease-modifying drugs such as methotrexate, sulfasalazine, and leflunomide (Arava), which can
be effective for joint inflammation of joints away from the spine, are not
effective for spinal inflammation. If nonsteroidal anti-inflammatory drugs
(NSAIDs) are not effective in a patient whose condition is dominated by spinal
inflammation (and 50% do respond), then biologic medications that inhibit tumor necrosis factor (TNF
inhibitors) are indicated. All TNF inhibitors, including Remicade, Enbrel, Humira, and Simponi are effective in treating ankylosing spondylitis. The improvement that results for TNF inhibition is sustained during years of treatment. If the TNF inhibitors are discontinued, for whatever reason, relapse of disease occurs in virtually all patients
within a year. If TNF inhibitor is then resumed, it is typically effective.
Oral or injectable corticosteroids (cortisone) are
potent anti-inflammatory agents and can effectively control
spondylitis and other inflammations in the body. Unfortunately, corticosteroids
can have serious side effects when used on a long-term basis.
These side effects include cataracts, thinning of the skin and
bones, easy bruising, infections, diabetes, and destruction of
large joints, such as the hips.
Physical therapy for ankylosing spondylitis includes instructions and exercises to
maintain proper posture. This includes deep breathing for lung expansion and
stretching exercises to improve spine and joint mobility. Since ankylosis of the
spine tends to cause forward curvature, patients are instructed to maintain
erect posture as much as possible and to perform back-extension exercises.
Patients are also advised to sleep on a firm mattress
and avoid the use of a pillow in order to prevent spine curvature.
Ankylosing spondylitis can involve the areas where the ribs attach
to the upper spine as well as the vertebral joints, thus limiting
breathing capacity. Patients are instructed to maximally
expand their chest frequently throughout each day to minimize
this limitation.
Exercise programs are customized for each individual. Swimming
often is a preferred form of exercise, as it avoids jarring impact of
the spine. Ankylosing spondylitis need not limit an individual's
involvement in athletics. People can participate in carefully chosen aerobic
sports when their disease is inactive. Aerobic exercise is generally encouraged as it promotes full
expansion of the breathing muscles and opens the airways of the lungs.
Inflammation and diseases in other organs are treated
separately. For example, inflammation of the iris of the eyes (iritis or uveitis) may require cortisone eyedrops (Pred
Forte)
and high doses of cortisone by mouth. Additionally, atropine eyedrops are often given to relax the muscles of the iris. Sometimes injections of cortisone into the affected eye are necessary when the inflammation
is severe. Heart disease in patients with ankylosing spondylitis, such as heart
block,
may require a pacemaker placement or medications for congestive
heart failure.
Cigarette smoking is strongly discouraged in people
with ankylosing spondylitis, as it can accelerate lung scarring
and seriously aggravate breathing difficulties. Occasionally,
those with severe lung disease related to ankylosing spondylitis
may require oxygen supplementation and medications to improve
breathing.
People with ankylosing spondylitis may need to modify their activities of daily living and adjust features of the workplace. For example, workers can adjust chairs and desks for proper postures. Drivers can use wide rearview mirrors and prism glasses to compensate for the limited motion in the spine.
Finally, orthopedic surgery maybe required when there is severe disease of the hip joints and spine.
Ankylosing Spondylitis - Symptoms at Onset of DiseaseQuestion: The symptoms of ankylosing spondylitis can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
There are many causes of back pain. Pain in the low back can relate to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area.
Crohn's disease is a chronic inflammatory disease,
primarily involving the small and large intestine, but which can
affect other parts of the digestive system as well. Abdominal pain, diarrhea, vomiting, fever, and weight loss are
common symptoms.
Ankle pain is commonly due to a sprain or tendinitis. The severity of ankle sprains ranges from mild (which can resolve within 24 hours) to severe (which can require surgical repair). Tendinitis of the ankle can be caused by trauma or inflammation.
Neck pain (cervical pain) may be caused by any number of disorders and diseases. Tenderness is another symptom of neck pain. Though treatment for neck pain really depends upon the cause, treatment typically may involve heat/ice application, traction, physical therapy, cortisone injection, topical anesthetic creams, and muscle relaxants.
Sacroiliac joint (SI) dysfunction is a general term to reflect pain in the SI joints. Causes of SI joint pain include osteoarthritis, abnormal walking pattern, and disorders that can cause SI joint inflammation including gout, rheumatoid arthritis, psoriasis, and ankylosing spondylitis. Treatment includes oral medications, cortisone injections, and surgery.
Ulcerative colitis is a chronic inflammation of the colon. Symptoms include abdominal pain, diarrhea, and rectal bleeding. Ulcerative colitis is closely related to Crohn's disease, and together they are referred to as inflammatory bowel disease. Treatment depends upon the type of ulcerative colitis diagnosed.
Arthritis is inflammation of one or more joints. When joints are inflamed they can develop stiffness, warmth, swelling, redness and pain. There are over 100 types of
arthritis including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, lupus, gout,
and pseudogout.
Psoriatic arthritis is a disease that causes skin and joint inflammation. Symptoms include painful, stiff, and swollen joints, tendinitis, and organ inflammation. Treatment involves antiinflammatory medications and exercise.
Bone spurs are pointy outgrowths of bone that develop in areas of inflammation or injury. They commonly occur on the heel and spine and may be the result of reactive arthritis, ankylosing spondylitis, or diffuse idiopathic skeletal hyperostosis. Symptoms include pain, numbness, and tenderness. Treatment focuses on decreasing inflammation and avoiding re-injury.
Costochondritis is inflammation of the cartilage where the ribs attach to the sternum. Tietze syndrome affects the same region of the chest and causes inflammation, tenderness, and swelling. Anti-inflammatory medications, rest, physical therapy, and cortisone injections are suitable methods of treatment for both costochondritis and Tietze syndrome.
Reactive arthritis is a chronic, systemic rheumatic disease characterized by three conditions, including conjunctivitis, joint inflammation, and genital, urinary or gastrointestinal system inflammation. Inflammation leads to pain, swelling, warmth, redness, and stiffness of the affected joints. Non-joint areas may experience irritation and pain. Treatment for reactive arthritis depends on which area of the body is affected. Joint inflammation is treated with antiinflammatory medications.
Juvenile arthritis (juvenile rheumatoid arthritis or JRA) annually affects one child in every thousand. There are three types of JRA: pauciarticular (less than four joints affected), polyarticular (more than four joints affected), and systemic-onset (inflamed joints with high fevers and rash). Treatment of juvenile arthritis depends upon the type the child has and should focus on treating the symptoms that manifest.
Kyphosis is outward curvature of the thoracic spine (upper back). Abnormal kyphosis results in the appearance of a hunchback, which is accompanied by back pain, stiffness, and muscle fatigue in the back. There are three types of abnormal kyphosis: postural, Scheuermann's, and congenital kyphosis. Postural kyphosis is caused by poor posture and a weakening of the back's muscles and ligaments. Scheuermann's kyphosis is caused by a structural deformity of the vertebrae. Congenital kyphosis is caused by an abnormal development of the vertebrae prior to birth. Treatment of kyphosis depends upon the type of kyphosis the patient has.
Iritis is inflammation of the iris, the colored portion of the eye. Symptoms include a red, painful eye, blurry vision, and light sensitivity. Treatment usually involves cortisone eyedrops.
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