How to manage ankylosing spondylitis effective guidance 4 main categories

Introduction

We will discuss how a Rheumatologist manage ankylosing spondylitis. If you are convinced based on my article “Ankylosing spondylitis, HLA B27, and confirming diagnosis” that you have ankylosing spondylitis, here I discuss treatments, mainly drugs called biologics. I discussed the concept of biologics in my article “What are biologics for a Rheumatologist? and what is Rheumatoid arthritis list of it?”. There I discussed what they are and their general issues.

Biologics: specifically anti-TNF

To give a brief, biologics turns off elements of the immune system that we think is over acting in you, leading to the disease. Biologics could increase risk of infections. Because they are proteins, your body might reject them, leading to allergic reaction. Some of these drugs have been initially used for Rheumatoid arthritis. But generally, we start with Humira, followed by Remicade infusion if former not effective. There are other anti-TNF such as Simponi/Aria and Cimzia that can be considered. Generally, I do not prefer Enbrel as it has been associated with uveitis (kind of autoimmune eye disease) which is already a potential issue when we manage ankylosing spondylitis.

Non-specific chemical drugs

You might ask why I did not start with oral immune calming meds like methotrexate – which I discussed in Rheumatoid arthritis article. These meds do not work for spine disease, therefore they are not primary medications. They can be used as addition if hands, feet, and peripheral joint has pains when biologics already controlled spine pain. Therefore these medications are not ideal for spine ankylosing spondylitis which is the main issue.

Psoriatic arthritis meds to manage ankylosing spondylitis

After anti-TNF category, or at least trying 2 of them, we move to IL 17 pathway medications such as Taltz or Cosyntex. I discussed their side effects in Psoriatic arthritis treatment suggestions.

Targeted chemical medication

Due to lower number of options for ankylosing spondylitis chemically specific pills such as Xeljanz can be considered. I will discuss benefits and risk of these meds in separate article as they are different category than biologics. It would be easier to discuss in separate article as they have been used on Rheumatoid arthritis and psoriatic arthritis. For ankylosing spondylitis, they are not part of standard therapy but can be considered if all other options are not possible.

Exercise

In regards to supervised physical therapy for ankylosing spondylitis, it seems it is as good as home exercise. I still see benefit for physical therapy visit to get the education on home exercise BUT I do not recommend recurrent physical therapy visits after initial education phase.

Corrective surgeries

Surgical options still exist but are becoming less common due to availability of better therapies that prevent severe cases. My role won’t be here to talk about surgeries. However, if you do have advanced case with permanent deformity preventing you from looking forward or driving a car, surgery is an option. I however recommend going to an academic center or a tertiary center. If the tertiary center did not have a specialist, you might want to go to a quaternary center such as Cleveland clinic or John Hopkins hospitals. Usually, unique procedures and surgeries are only possible in large hyper specialized centers that see complex cases.

Summary

What if after biologics there is still some spine pain? However, the patient is worried about changing medications, then a possible addition to relieve pain is spinal or sacroiliac injections. Typically, these are provided by intervention pain clinic. Although they might not treat the disease but are valid option to reduce pains. These interventions are discussed in “How to manage osteoarthritis?”. Despite these therapies being designed for osteoarthritis, they could help and are used to manage ankylosing spondylitis.