What are the treatments for ankylosing spondylitis?
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The aims of treatment are: to ease pain and stiffness, to keep your spine as mobile and flexible as possible, and to limit the extent of any deformity.
PHYSIOTHERAPY AND EXERCISE
It is vital to have a good posture and a regular exercise routine. This helps you to keep a full range of spinal movement and may help to prevent your spine from stiffening up. Regular specific exercises are thought to limit the extent of any spinal deformity that may develop. The exercises may also ease back pain. You will normally be referred to a physiotherapist who will advise on the exact exercises to do. Exercises should become a routine part of life. Ideally, they should be done daily.
MEDICATION
Anti-inflammatory medicines
Anti-inflammatory medicines reduce inflammation and ease pain. Their correct name is non-steroidal anti-inflammatory drugs (NSAIDs). An important reason to take these medicines is to ease pain so that you can do regular exercises without much discomfort.
It is thought that anti-inflammatory medicines only ease symptoms but do not alter the course of the disease. Therefore, advice had been to take these medicines as and when the pain flares up. But then if symptoms ease, not to take them. However, a recent research study has suggested that regular long-term use of anti-inflammatory medicines may slow down the progression of AS. Further studies are needed to confirm this.
There are several different anti-inflammatory medicines - for example, ibuprofen, diclofenac and naproxen - but there are many others. If one does not suit, another may be fine. Side-effects sometimes occur with these medicines. For example:
Stomach pain and bleeding from the stomach are the most serious. The risk of this is higher if you are aged over 65, or have had a duodenal or stomach ulcer. In some situations, your doctor may prescribe another medicine to protect the stomach from these possible problems. If you develop abdominal (stomach) pains, pass blood or black stools, or vomit blood whilst taking anti-inflammatory medicines, stop taking the tablets and see a doctor urgently.
You may not be able to take anti-inflammatory medicines if you have asthma, high blood pressure, kidney failure, or heart failure.
The leaflet which comes with the tablets gives a full list of possible side-effects.
Ordinary painkillers
Painkillers such as paracetamol may be sufficient if symptoms are mild between flare-ups. (But note the comment above about the possible benefits of taking long-term anti-inflammatory medicines.) You can also take paracetamol in addition to an anti-inflammatory medicine for top-up pain relief.
Immunosuppressant medicines
Newer powerful medicines have become available in recent years that suppress the immune system. They tend to be divided into two groups, biological therapies and immunomodulators. Immunomodulators are useful in rheumatoid arthritis but recent research suggests they are not very effective in AS. Biological therapies, however, have made a signficant impact on the treatment of AS.
Biological therapies are genetically engineered proteins such as special antibodies called monoclonal antibodies. They can target specific chemicals of the immune system involved in the inflammation process. In AS, a chemical called cytokine tumour necrosis factor alpha (TNF-alpha) is involved in the inflammation process. Certain medicines in a group called TNF-alpha antagonists (which are really manufactured antibodies) block the action of this chemical and therefore suppress the disease activity.
The TNF-alpha antagonists recommended by the National Institute for Health and Clinical Excellence (NICE) are etanercept, adalimumab and golimumab. Treatment with one of these medicines is an option in some cases. Etanercept or adalimumab need to be given by injection every 1-6 weeks depending of the dose and type. Golimumab needs to be injected every month. The medicines require special monitoring, as some people develop serious side-effects. For example, taking these medicines can make you more prone to develop a serious infection. A specialist may advise using one of these medicines if you have moderate or severe AS which has not been helped much by anti-inflammatory medicines.
Regarding TNF-alpha antagonists, the NICE guidelines state:
"Adalimumab and etanercept are recommended as possible treatments for people with severe ankylosing spondylitis who:
Have active spinal disease as assessed on two occasions 12 weeks apart, and
Have tried at least two non-steroidal anti-inflammatory drugs (NSAIDs) but they have not worked.
Treatment should be started and supervised by a specialist who is experienced in diagnosing and treating AS. People taking adalimumab or etanercept should have regular check-ups. Treatment should continue only if the person's AS shows an adequate improvement. If the improvement is not maintained or if the medicine stops working then treatment should be stopped. Infliximab is not recommended."
Similar considerations should apply to golimumab.
Other medication
Occasionally, other medicines are used:
A steroid injected directly into a badly inflamed joint is sometimes used to ease symptoms.
Medicines called bisphosphonates are used to treat osteoporosis that is associated with AS.
OTHER TREATMENTS
Other treatments sometimes used include the following:
Transcutaneous electrical nerve stimulation (TENS) machines are sometimes used to ease pain. (These give tiny electrical currents into the affected area.)
Heat - for example, a hot shower - may help to ease pain, particularly each morning.
Some people find regular massage is soothing.
About 1 in 20 people with AS need a hip replacement at some stage, as their hip sometimes becomes badly affected. Rarely, surgery is needed to correct a severe spinal deformity.
Ankylosing spondylitis and cardiovascular disease
If you have AS, you have an increased risk of developing cardiovascular disease when you become older. (Cardiovascular disease refers to narrowing of the arteries by a fatty substance called atheroma. This may eventually lead to conditions such as angina, heart attack or stroke.) It is not clear why the risk is increased in people with AS. It may be that the chronic (persistent) inflammatory nature of the condition is partially responsible. Therefore, you should consider doing what you can to reduce the risk of cardiovascular disease by other means.
For example, if possible:
Eat a good healthy diet.
Exercise regularly.
Lose weight if you are overweight.
Do not smoke.
If you have high blood pressure, diabetes, or a high cholesterol level, they should be well controlled on treatment.
See leaflet called 'Preventing Cardiovascular Diseases' for details.
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