Ankylosing Spondylitis (cont.)
What are treatment options for ankylosing
spondylitis?
The treatment of ankylosing spondylitis 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 antiinflammatory 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 patients with ankylosing spondylitis,
inflammation
of joints excluding the spine (such as the hips, knees, or ankles) become the major problem. Inflammation in these joints may not respond to NSAIDs alone.
In these patients, the addition of medications that suppress the body's immune system
are 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 antiinflammatory medications, both sulfasalazine and methotrexate are ineffective. Newer, effective medications for spine disease attack a messenger protein of inflammation (called 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),
and adalimumab (Humira).
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 antiinflammatory 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, and Humira 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 in a year. If TNF inhibitor is then resumed, it is typically effective.
Oral or injectable corticosteroids (cortisone) are
potent antiinflammatory 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 the individual
patient. Swimming is preferred, as it avoids jarring impact of
the spine. Ankylosing spondylitis need not limit a patient's
involvement in athletics. Patients 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
may require a pacemaker placement or medications for congestive
heart failure.
Cigarette smoking is strongly discouraged in patients
with ankylosing spondylitis, as it can accelerate lung scarring
and seriously aggravate breathing difficulties. Occasionally,
patients with severe lung disease related to ankylosing spondylitis
may require oxygen supplementation and medications to improve
breathing.
Patients 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, patients who have severe disease of the
hip joints and spine may require orthopedic surgery.
Next: What is in the future for patients with ankylosing spondylitis? »
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