Treating ankylosing spondylitis

There is no cure for ankylosing spondylitis (AS), but treatment is available. It aims to:

  • relieve your symptoms
  • prevent your symptoms from interfering with your daily life
  • slow the process of stiffening of your spine

Ankylosing spondylitis is a chronic (long-term) condition, but most people who are affected by it are fully independent and lead relatively normal lives.

If your GP thinks you have ankylosing spondylitis, they may prescribe medicines to control your symptoms. You will probably be referred to a rheumatologist (a specialist in conditions that affect the bones, muscles and joints).

The rheumatologist will advise you and your GP about continuing your treatment using:

  • physical treatments, such as physiotherapy (where physical methods, such as exercise and manipulation, are used to improve your symptoms and wellbeing)
  • medication to control the pain and relieve the symptoms

These treatments are described in more detail below.

Physiotherapy

Physical activity and exercise are very important for effectively treating ankylosing spondylitis effectively. Keeping active can improve your posture and your range of spinal movement, as well as preventing your spine from becoming stiff and painful.

As well as keeping active, physiotherapy is a key part of treating ankylosing spondylitis. Your rheumatologist will be able to refer you to a physiotherapist (a healthcare professional who is trained in using physical methods of treatment). They can advise you about the best ways to exercise. They can also draw up an exercise programme that is suitable for you.

If you have ankylosing spondylitis, the type of physiotherapy that may be recommended may include:

  • a group exercise programme, where you exercise with other people
  • an individual exercise programme – you are given exercises to do by yourself
  • massage – your muscles and other soft tissues are manipulated to relieve pain and improve movement 
  • hydrotherapy – you exercise in water (usually a warm, shallow swimming pool or a special hydrotherapy bath); the weight of the water helps to improve your circulation (blood flow), relieve pain and relax your muscles
  • electrotherapy – electric currents or impulses (small electric shocks) make your muscles contract (tighten), which can help ease pain and promote healing

Some people prefer to swim or play sport to keep flexible. This is usually fine, although some daily stretching and exercise is also important (see below).

See the Health A-Z topic about Physiotherapy for more information about the wide range of different techniques that can be used.

Exercise

The National Ankylosing Spondylitis Society (NASS) provides detailed information about different types of exercise that may help you to effectively manage your condition.

However, if you are in doubt, get advice from your physiotherapist or rheumatologist before taking up a new form of exercise or sport.

Alongside physiotherapy, you will also probably be prescribed medication. The different types of medications that you may be prescribed include:

  • painkillers
  • tumour necrosis factor (TNF) blockers
  • bisphosphonates
  • disease-modifying anti-rheumatic drugs (DMARDs)
  • corticosteroids

These are described below.

Painkillers

Your GP may prescribe painkillers to manage your condition while you are being referred to a rheumatologist. The rheumatologist may continue prescribing painkillers, although not everyone needs them, at least not all the time. The first type of painkiller that is usually prescribed is a non-steroidal anti-inflammatory drug (NSAID).

Non-steroidal anti-inflammatory drugs (NSAIDs)

As well as helping to ease pain, non-steroidal anti-inflammatory drugs (NSAIDs) will also help to relieve inflammation (swelling) in your joints. Therefore, they are usually an effective treatment for ankylosing spondylitis. Examples of NSAIDs include:

  • ibuprofen
  • naproxen 
  • diclofenac

When prescribing NSAIDs, your GP or rheumatologist will try to find the one that suits you best and the lowest possible dose that relieves your symptoms. Your dose will be monitored and reviewed as necessary.

Cautions

NSAIDs may be unsuitable for you if you:

  • have asthma – a condition that causes the airways of the lungs (the bronchi) to become inflamed 
  • have high blood pressure (hypertension
  • have kidney or heart problems
  • have, or have previously had, stomach problems, such as a peptic ulcer
  • are pregnant 
  • are also taking other medications, such as aspirin or warfarin (medicine to stop your blood clotting)

See the Health A-Z topic about NSAIDs for more information.

Paracetamol

If NSAIDs are unsuitable for you, an alternative painkiller, such as paracetamol, may be recommended.

Paracetamol rarely causes side effects and can be used in women who are pregnant or breastfeeding. However, paracetamol may not be suitable for people with liver problems or those who are dependent on alcohol (have an alcohol addiction).

Codeine

If necessary, as well as paracetamol, you may also be prescribed a stronger type of painkiller called codeine. Codeine can cause side effects including:

  • nausea (feeling sick)
  • vomiting (being sick)
  • constipation (an inability to empty your bowels)
  • drowsiness, which could affect your ability to drive

Tumour necrosis factor (TNF) blocker

If your symptoms of ankylosing spondylitis cannot be controlled using painkillers or exercising and stretching, a tumour necrosis factor (TNF) blocker may be recommended for you. TNF is a chemical that is produced by cells when tissue is inflamed.

TNF blockers are given by injection and work by preventing the effects of TNF. This helps reduce the inflammation in your joints that is caused by ankylosing spondylitis. Examples of TNF blockers include:

  • adalimumab
  • etanercept

Side effects

Side effects from adalimumab and etanercept include:

  • reactions at the site of the injection, such as redness or swelling
  • infections, which can be severe, such as tuberculosis (an infection of the lungs) or septicaemia (blood poisoning) 
  • nausea (feeling sick)
  • abdominal (tummy) pain
  • headache

See the patient information leaflet that comes with your medication for a full list of side effects.

TNF alpha blockers are a relatively new form of treatment for ankylosing spondylitis, and their long-term effects are unknown. However, research into the use of TNF blockers for treating rheumatoid arthritis (a type of arthritis that makes your joints feel stiff and can leave you feeling tired and unwell) is providing clearer information about their long-term safety.

If your rheumatologist recommends using TNF blockers, the decision about whether they are right for you must be discussed carefully, and your progress will be closely monitored. The main reason for this is that TNF blockers interfere with the immune system (the body’s natural defence system).

NICE guidelines

The National Institute for Health and Clinical Excellence (NICE) has produced guidance about the use of these TNF blockers. NICE states that adalimumab and etanercept may only be used if:

  • your diagnosis of ankylosing spondylitis has been confirmed (see Ankylosing spondylitis – diagnosis)
  • your level of pain is assessed twice (using a simple scale that you fill in) 12 weeks apart and confirms that your condition is still active (has not improved)
  • your Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is tested twice, 12 weeks apart, and confirms that your condition is still active (BASDAI is a set of measures devised by experts to evaluate your condition by asking a number of questions about your symptoms)
  • treatment with two or more NSAIDs for four weeks at the highest possible dose has not controlled your symptoms 

After 12 weeks of treatment with adalimumab or etanercept, your pain score and BASDAI will be tested again to see whether or not they have improved sufficiently to make continued treatment worthwhile for you. If they have, treatment with adalimumab or etanercept will continue and you will be tested every 12 weeks.

If there is not enough improvement after 12 weeks, you will be tested again after six weeks. If treatment with adalimumab or etanercept is still not effective, the treatment will be stopped.

If you cannot understand the BASDAI and pain tests, for example, because of a learning difficulty or because they are not available in a language you easily understand, it will be possible to assess the appropriateness and effects of TNF blocker drugs in other ways (an alternative method of assessment may be used).

Infliximab is an alternative TNF blocker that may be used to treat ankylosing spondylitis. However, it is not recommended by NICE. If you are currently taking infliximab, you should continue to do so until you and your rheumatologist decide that it is appropriate for you to stop.

Other new TNF blockers and similar medications are being developed and may be approved by NICE.

Bisphosphonates

Bisphosphonates are usually used to treat osteoporosis (weak and brittle bones), which can sometimes develop as a complication of ankylosing spondylitis. Bisphosphonates may also be effective in treating ankylosing spondylitis, although the evidence is not entirely clear. They may be used if you also have osteoporosis. 

Bisphosphonates can be taken by mouth (orally) as tablets or given by injection.

Disease-modifying anti-rheumatic drugs (DMARDs)

Disease-modifying anti-rheumatic drugs (DMARDs) are an alternative type of medication that is often used to treat other types of arthritis, such as rheumatoid arthritis. DMARDs may be prescribed for ankylosing spondylitis, although they are only beneficial if other joints are involved rather than the spine.

Two DMARDs have been studied for possible benefits in people with ankylosing spondylitis. Both may be helpful for inflammation of joints other than the spine, although neither seems to be helpful for spinal symptoms. They are:

  • sulfasalazine
  • methotrexate

Both are known to be effective for treating rheumatoid arthritis, but there is not currently enough evidence of the benefits of methotrexate for ankylosing spondylitis.

Sulfasalazine

Sulfasalazine can cause a number of side effects, such as:

  • nausea
  • vomiting
  • heartburn (when stomach acid leaks back up into your gullet)
  • serious skin reactions

Corticosteroids

Corticosteroid medicines (steroids) have a powerful anti-inflammatory effect and can be taken in various ways, for example as:

  • tablets (oral)
  • injections (parenteral)

If a particular joint is inflamed, corticosteroids  can possibly be injected directly into the joint. Corticosteroids are sometimes used to treat other types of arthritis because they can reduce the pain, stiffness and swelling in a joint.

After the injection you will need to rest the joint for up to 48 hours (two days). It is usually considered wise to have a corticosteroid injection up to three times in one year, with at least three months between injections in the same joint. This is because corticosteroids injections can cause a number of side effects, such as:

  • inflammation in response to the injection
  • the skin around the injection may change colour (depigmentation)
  • the surrounding tissue may waste away
  • a tendon (cord of tissue that connects muscles to bones) near the joint may rupture (burst)

Corticosteroids may also help to calm down painful swollen joints when taken as tablets. Occasionally, when pain and stiffness are severe, corticosteroids can be very helpful when given as an injection into your muscle (intramuscular injection).

See the Health A-Z topic about Corticosteroids for more information about this type of medication.

Data from: http://www.nhs.uk/Conditions/Ankylosing-spondylitis/Pages/Treatment.aspx

TREATMENT OF ANKYLOSING SPONDYLITIS & RELATED DISEASES

A common treatment regimen for all the spondyloarthropathies (ankylosing spondylitis, reactive arthritis, psoriatic arthritis, enteropathic arthritis, and undifferentiated spondyloarthropathy) involves medication, exercise and possibly physical therapy, good posture practices, and other treatment options such as applying heat/cold to help relax muscles and reduce joint pain. In severe cases of ankylosing spondylitis, surgery may also be an option.

Depending on the type of spondyloarthritis, there may be some variation in treatment. For example, in psoriatic arthritis, both the skin component and joint component must be treated. In enteropathic arthritis (spondylitis/arthritis associated with inflammatory bowel disease such as Crohn’s or ulcerative colitis), medications may need to be adjusted so the gastrointestinal component of the disease is not exacerbated.

Very often, a rheumatologist will be the one to outline a treatment plan, but other professionals may also be able involved in your care. (Click here for medical team information).

Medication
NSAIDs (nonsteroidal anti-inflammatory drugs) are still the cornerstone of treatment and the first stage of medication in treating the pain and stiffness associated with spondylitis. However, NSAIDs can cause significant side effects, in particular, damage to the gastrointestinal tract.

When NSAIDs are not enough, the next stage of medications, (also known as second line medications), are sometimes called disease modifying anti-rheumatic drugs (DMARDS). This group of medications include: Sulfasalazine, Methotrexate and Corticosteroids.

The most recent and most promising medications for treating ankylosing spondylitis are the biologics, or TNF Blockers. These drugs have been shown to be highly effective in treating not only the arthritis of the joints, but also the spinal arthritis. Included in this group are Enbrel, Remicade, Humira and Simponi. Click here to learn more in the medications section.

Exercise
Exercise in an integral part of any spondylitis management program. Regular daily exercises can help create better posture and flexibility as well as help lessen pain.

A properly trained physical therapist with experience in helping those with ankylosing spondylitis can be a valuable guide in regard to exercise. Click here to learn more about exercise.

Posture
Practicing good posture techniques will also help avoid some of the complications of spondylitis including stiffness and flexion deformities / kyphosis (downward curvature) of the spine. Click here to learn more about posture.

Heat/Cold
Applying heat to stiff joints and tight muscles can help reduce pain and soreness. Applying cold to inflamed areas can help reduce swelling. Hot baths and showers can also help provide relief.

Surgery
In severe cases of ankylosing spondylitis, surgery can be an option in the form of joint replacements, particularly in the knees and hips. Surgical correction is also possible for those with severe flexion deformities (severe downward curvature) of the spine, particularly in the neck, although this procedure is considered risky. Click here to learn more about surgery.

Other Symptom Management Tools
Alternative treatments such as massage and using a TENS unit (electrical stimulators for pain) can also aide in pain relief. Maintaining a healthy body weight and balanced diet can also aide in treatment. Click here for more information on alternative treatments.

Data from: http://www.spondylitis.org/about/treatment.aspx

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