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 non-steroidal 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 disease-modifying antirheumatic drugs (DMARDs) 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.
Medical 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). In 2016, adalimumab (Humira) was approved for the treatment of uveitis (inflammation in the eyes).
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.
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.
Finally, orthopedic surgery may be required when there is severe disease of the hip joints and spine.