Ankylosing Spondylitis - Treatments

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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.

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 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. 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 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.

Return to Ankylosing Spondylitis

See what others are saying

Comment from: thush, 35-44 Female (Patient) Published: October 31

My first symptoms of ankylosing spondylitis started when I was 24. I got this terrible pain behind my ears. When I went to my family doctor he said I am getting my wisdom teeth. But I never did get any wisdom teeth. After 6 months I got a back ache, then stiff neck. I consulted a doctor, and he gave me some pain killers and I was ok for about 4 months. Then I got a red eye and my eye specialist gave me some drops. Then I got this unbearable neck pain again. I told my doctor to do all possible tests. He took an X-ray of my neck and said I have cervical spondylosis plus extra upper rib. After two weeks I went to see the same doctor since I developed a pain on my heel. He said it's impossible, he told me to continue with my exercise. Nothing helped, doctor after doctor, I was feeling that I have fever, but no temperature. My blood test shows that I am anemic so my family doctor gave me iron tablets. I have to say I am a vegetarian so my family and friends said it's due to it. For last three years I feel tired all the time. But I manage to do all my work still doing it. Last year my right eye got red again so I went to see eye surgeon. She gave me some medicine, and I was ok. But within three days I got it again. My eye doctor said to stop my shampoo, etc. And gave me some more drops. Again I got a red eye within two weeks , and this time my eye doctor asked if I have any back pain I said yes, and she asked me why didn't I tell her beforehand (how am I supposed to know there is a link). I was referred to a rheumatologist .Now I know it's not my mind. At least I am mentally OK though I am depressed. Only thing that helps me is pain killers, heat pad, sleeping on the floor, flat surface. I do exercises regularly. I don't get proper sleep.

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Comment from: helenb, 55-64 Female (Patient) Published: May 20

Recently, I was diagnosed with inflammatory spinal disease. I have suffered on and off for years with back problems starting in my early 20s when I was told it was sciatica. I also suffered for years with excruciating spasms between my shoulder blades, for which I was given quinine sulfate but no diagnosis. I also suffered from hip pain off and on too. After putting up with lower back pain for many years, receiving painkillers, and anti-inflammatories, I finally asked for a referral to a rheumatologist. This happened for two reasons: my daughter started suffering from the same between the shoulders pain and was referred very quickly; and due to the fact that I had had to take off lots of time from work because I couldn't move because of the pain and, literally, my legs wouldn't hold me up. My daughter was told she had the HLA-B27 marker and that it was hereditary. This is the main reason I asked for a referral. It was confirmed that I have AS with bone spurs attached to the next vertebrae in my lower back and between my shoulders. I was assessed by a physiotherapist a few days ago, who told me I also have a scoliosis on my right side. So glad my daughter is receiving the help I wish I had received years ago.

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