Treatment of Ankylosing Spondylitis

Guidelines According to the American College of Rheumatology

Physical therapist guiding woman pulling resistance band overhead
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While there is no cure for ankylosing spondylitis (AS), a treatment regimen that consists of physical therapy and medication can effectively ease a person's symptoms of joint pain, stiffness, and swelling, and also improve everyday functioning.

In 2015, the American College of Rheumatology (ACR) created guidelines for treating ankylosing spondylitis. These guidelines were meant to help doctors optimize the care of their patients with AS in a systematic way, based on research studies.

As a person with AS (or if you have a loved one with AS), knowledge about treatment guidelines will help you navigate this complex and chronic disease more assuredly and confidently.

Non-steroidal Anti-Inflammatory (NSAID) Therapy

The mainstay treatment for ankylosing spondylitis is non-steroidal anti-inflammatory (NSAID) therapy.

NSAIDs have been around a long time and are very effective at reducing inflammation in the body. They work by blocking enzymes called cyclooxygenase enzymes (COX enzymes). By blocking these enzymes, prostaglandin levels are reduced in the body. Since prostaglandins play a key role in inflammation, by reducing them, symptoms of inflammation like pain and swelling are minimized.

The downside of NSAIDs is that they cannot be taken by everyone, due to their potential for harm. This is why it's extremely important to only take a NSAID under the guidance of your doctor.

For instance, one well-known potential harm of NSAID therapy is that it may cause stomach damage, ulcers, and bleeding.

NSAIDs can also increase your risk of heart attack, heart failure, or stroke. They may also raise a person's blood pressure and cause or worsen kidney problems.

In addition to these potential harms, NSAIDs may interact with your other medications. This is why it is important to tell your doctor all of the medications you are taking, including herbals, vitamins, or supplements.

Examples of NSAIDs

There are a number of different NSAIDs available to treat AS, including both over-the-counter NSAIDs and prescription NSAIDs. Examples include:

  • over-the-counter NSAIDs: Advil or Motrin (ibuprofen) and Aleve (naproxen)
  • prescription NSAIDs: Voltaren (diclofenac), Mobic (meloxicam), or Indocin (indomethacin).

Over-the-counter NSAIDs like ibuprofen are also available by prescription at a higher strength.

Another type of NSAID commonly prescribed to treat AS is Celebrex (celecoxib), which may help prevent stomach and intestinal problems from occurring.

Celebrex is a selective-NSAID because it blocks COX-2 enzyme only (other NSAIDs block COX-1 and COX-2 enzymes). By preserving the function of COX-1 and only blocking COX-2, stomach, and intestinal injury is reduced—this is because COX-1 helps maintain the gastrointestinal lining.

Tumor Necrosis Factor Inhibitors (TNFi)

If a person with AS cannot take a NSAID, or if their symptoms like pain and stiffness are not improved with NSAID therapy, a TNF blocker is recommended.

Tumor necrosis factor (TNF) is a protein involved in the inflammatory process, so by inhibiting its production, inflammation in the body is reduced. 

The good news about TNF blockers is that there is ample scientific evidence to support their benefit in reducing disease activity in ankylosing spondylitis—in other words, quieting the inflammation down in the body. Still, TNF blockers are not benign therapies. They do have risks, and this must be weighed carefully for each individual person.

Due to the fact that TNF blockers suppress a person's immune system (albeit an overactive one in the cases of those with ankylosing spondylitis), they can increase a person's risk of both mild infection and serious infection.

An example of a mild infection is a common cold. On the other hand, a serious infection that doctors especially worry about when a person is taking a TNF inhibitor is tuberculosis. Due to this risk of tuberculosis reactivation, a TB test is required before initiating TNF blocker therapy. Rarely, TNF blockers have been linked to an increased chance of developing certain cancers.

It's also important to know that certain people are not candidates for taking TNF blockers like those with:

  • multiple sclerosis (TNF blockers rarely worsen the loss of myelin in the brain and spinal cord)
  • heart failure
  • an active infection like pneumonia

Women who are pregnant or breastfeeding are also not candidates for TNF blocker therapy.

Examples of TNF Blockers

In 2010, the Assessment of SpondyloArthritis International Society (ASAS) published a set of guidelines  for using TNF blockers in patients with ankylosing spondylitis. These guidelines help doctors determine who is a good candidate for TNF blocker therapy.

For example, according to the ASAS criteria, a person should only be considered for a TNF blocker if their disease does not improve with at least two different types of NSAIDs (at maximum dose tolerated).

The TNF blockers used to treat ankylosing spondylitis are:

  • Enbrel (etanercept)
  • Remicade (infliximab)
  • Humira (adalimumab)
  • Simponi (golimumab)
  • Cimzia (certolizumab)

Remicade (infliximab) is given as an infusion through the vein while Enbrel (etanercept), Humira (adalimumab), Simponi (golimumab), and Cimzia (certolizumab) are given as subcutaneous (into the fat tissue) injections.

Physical Therapy

In addition to medication, the American College of Rheumatology recommends physical therapy for people with active AS (meaning symptoms of inflammation like joint pain and stiffness). This recommendation is based on a number of studies that have found physical therapy to be beneficial in reducing pain and improving spinal mobility, posture, flexibility, physical functioning, and well-being.

In addition, there is little harm associated with physical therapy. The good news is that either individual home physical therapy or supervised group physical therapy works—although research suggests that supervised group physical therapy may be more  beneficial than home exercises.

What may be even more appealing (and luxurious) for those with AS is a type of therapy called spa-exercise therapy, which includes exercising in warm water, massage from hydrotherapy jets, and relaxing in a steamy sauna. In fact, research has found that spa-exercise therapy combined with group physical therapy is better than group physical therapy alone.

Surgery

In rare instances, surgery is needed to treat ankylosing spondylitis. This is usually reserved for people with severe hip joint damage and pain—in these instances, a total hip replacement is often recommended over no surgery at all. Riskier surgeries like those involving the spine are much less common and performed when there is severe downward curving of the spine ("hunchback posture.")

A Word From Verywell

Ankylosing spondylitis is a chronic disease, and there is no cure. But there are ways to manage it. With the right treatment regimen (which will need tweaking over time under your doctor's guidance), you can live well with AS.

Sources:

Callhoff J et al. Efficacy of TNFα blockers in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: a meta-analysis. Ann Rheum Dis. 2015 Jun;74(6):1241-8.

Dagfinrud H, Kvien TK, Hagen KB. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD002822.

van der Heijde D et al. 2010 Update of the international ASAS recommendations for the use of anti-TNF agents in patients with axial spondyloarthritis. Ann Rheum Dis. 2011 Jun;70(6):905-8.

van Tubergen et al. Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Arthritis Rheum. 2001 Oct;45(5):430-8

Ward MM et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2016 Feb;68(2):282-98.

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