Ankylosing spondylitis and liver involvement
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Ankylosing spondylitis (AS) is a chronic inflammatory form of arthritis that affects the spine and peripheral joints.
The hallmark feature of AS is the involvement of the joints at the base of the spine where the spine joins the pelvis - the sacroiliac (SI) joints.
The disease course is highly variable, and while some individuals have episodes of transient back pain, others have more chronic severe back pain that leads to varying degrees of spinal stiffness over time. In almost all cases the disease is characterized by a roller coaster of acute painful episodes and remissions.
AS is a member of the family of inflammatory diseases of the spine called the spondylarthropathies. In addition to AS, these diseases include Reiter’s syndrome, psoriatic arthritis and the arthritis of inflammatory bowel disease.
Men develop ankylosing spondylitis three times more often than women. It usually appears in people between the ages of 15 and 40.
AS is three times more common in men than in women. It typically affects young people, beginning between the ages of 15 and 30. It may affect younger people also, although in very young people it may take a slightly different form, causing pain around the heels, knees, and hips rather than beginning with the spine. Onset after age 40 is uncommon.
Involvement of internal organs is unusual. Rarely, the lungs may be affected. Patients with longstanding AS may develop a condition called amyloidosis which can cause protein to leak out through he kidneys. Patients with inflammatory bowel disease will have bowel involvement as well as low grade liver involvement.
The most common type of medicine used early to treat ankylosing spondylitis is non-steroidal anti-inflammatory drugs (NSAIDs). These drugs help reduce the pain and swelling of the joints and decrease stiffness. However, they do not prevent further joint damage.
Taking NSAIDs increases the possibility of side effects, particularly stomach problems such as heartburn, ulcers and bleeding. People on these medications should consider taking something to protect the stomach. NSAIDS also increase the risk of cardiovascular events such as heart attack and stroke.
For those with severe disease, a drug called sulfasalazine can help manage the symptoms, and better control the disease. Sulfasalazine is one type of a family of medicines called disease-modifying anti-rheumatic drugs (DMARDs). DMARDs are used to slow disease down. DMARDS take about two to six months before they begin to kick in.
Disease modifying anti-rheumatic drugs (DMARDs) may be prescribed when disease remains active. DMARDs target the processes causing the inflammation, but do not reverse permanent joint damage. The most common of them are methotrexate, sulfasalazine, hydroxychloroquine, and azathioprine. A DMARD is usually prescribed in addition to an NSAID or prednisone. Side effects may include mouth sores, diarrhea and nausea. More serious side effects, monitored through regular blood and urine tests, include liver damage, and excessive lowering of white blood cell count (increasing susceptibility to certain infections), and platelet count (affecting blood clotting).
Patients on NSAIDS and DMARDS need to have their liver function monitored closely.
Biologic medications such as TNF inhibitors (Enbrel, Humira, Remicade, Simponi, Cimzia) have revolutioneized the treatment of AS. These medicines should be used earlier rather than later to induce remission. They also have rarely been associated with liver function abnormalities.
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