Ankylosing Spondylitis (cont.)
William C. Shiel Jr., MD, FACP, FACR
William C. Shiel Jr., MD, FACP, FACR
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.
Catherine Burt Driver, MD
Catherine Burt Driver, MD
Catherine Burt Driver, MD, is board certified in internal medicine and rheumatology by the American Board of Internal Medicine. Dr. Driver is a member of the American College of Rheumatology. She currently is in active practice in the field of rheumatology in Mission Viejo, Calif., where she is a partner in Mission Internal Medical Group.
In this Article
What are ankylosing spondylitis treatment options?
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.
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 used. All TNF inhibitors, including Remicade, Enbrel, Humira, and Simponi can be 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. So they are typically used for short periods when possible. These side effects include cataracts, thinning of the skin and bones (osteoporosis), 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 can be a very beneficial 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 may be required when there is severe disease of the hip joints and spine.
Medically Reviewed by a Doctor on 7/17/2015
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Ankylosing Spondylitis - Symptoms Question: The symptoms of ankylosing spondylitis can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Ankylosing Spondylitis - Treatments Question: What was the treatment for your ankylosing spondylitis?
Ankylosing Spondylitis - Experience Question: Please describe your experience with ankylosing spondylitis.
Ankylosing Spondylitis - Severity and Progression Question: Do you or a relative have ankylosing spondylitis? Please share its progression, along with treatments.
Ankylosing Spondylitis - Diagnosis Question: What tests led to a diagnosis of ankylosing spondylitis?
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