Treatment of anklosing spondylitis

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 relatively common form of inflammatory arthritis that affects the spine.

AS is in the category of diseases designated as the “spondyloarthropathies.” Other members of this group include psoriatic arthritis and reactive arthritis. The term spondyloarthropathy refers to the propensity for spinal involvement.

There is a strong genetic predilection with 90 per cent of Caucasian patients showing the presence of the HLA B27 genetic marker. Many AS patients will have a positive family history for the disease.

Spondyloarthropathies, in general, cause early erosion and damage. Usually the sacroiliac joints (joints joining the pelvis to the sacrum of the spine) are involved first with gradual involvement of the rest of the spine following. As the disease progresses, there is gradual destruction of joints with bony bridging leading to marked deformity and loss of function. Women tend to have more neck involvement while men tend to have more low back involvement.

Like the other spondyloarthropathies, AS is an enthesopathy causing inflammation at the site where the tendon inserts into bone.

AS occurs in about 0.5 per cent of the population. It is more common in men than women in a ratio of about 5:1. It should be mentioned that AS is probably under diagnosed in women. When AS does affect women, it tends to happen a bit later, have less hip involvement, have more symphysis pubis involvement, and definitely more cervical spine (neck) involvement.

The peak age of onset is in the 15 to 30 age range.

Symptoms usually begin in young adulthood. Low back stiffness and pain are usually the first symptoms. Low back morning stiffness is relieved by activity and anti inflammatory medication. Symptoms of fever, weight loss, and reduced appetite may be seen. With progression, there is restricted ability to walk and a reduction in the ability to perform activities of daily living.

Physical examination shows restricted range of motion in the spine and muscle spasm as well. Chest expansion may be restricted.

Patients with AS also have inflammatory arthritis affecting peripheral joints in a non symmetric fashion. The hip joints may be severely affected. Other afflicted joints include the ankles, shoulders, elbows, wrists, hands, and feet.

AS is a systemic disease. Eye involvement is seen in up to 40 per cent. It is common in B27 positive patients. It is acute, unilateral (one side), accompanied by pain, and will lead to progressive visual loss.

Other systemic problems include inflammation of the aortic valve and conduction system in the heart and scarring in the lungs.

As AS progresses, there is increasing risk for spinal fracture. This is a danger in patients with severe neck involvement who require intubation for surgical procedures.

Laboratory tests will demonstrate elevated erythrocyte sedimentation tests. The presence of HLA B27, while not essential, is helpful.

X-rays are often normal in early disease. As sacroileitis progresses, evidence of erosion and even fusion may be seen. Late findings show complete fusion of all the vertebrae.

AS needs to be differentiated from other causes of low back pain. AS should be considered in patients who present at a young age, have a positive family history of back pain, have low back symptoms lasting longer than 3 months, have prolonged morning stiffness, have improvement with exercise/ activity, have limited spinal mobility, and have an elevated erythrocyte sedimentation rate.

There appears to be a subset of patients with axial (spinal) spondyloarthropathy that is B27 negative, yet behaves like classic ankylosing spondylitis.

Goals of treatment include reduction of pain and stiffness, maintenance of mobility and posture, restoration of normal activities of daily living, and disease remission.

Patient education, joint protection, physical and occupational therapy, dietary and vocational counseling should be instituted.

The benefits of a regular exercise program cannot be underestimated.

Non steroidal anti inflammatory drugs are often effective for symptom relief. They do not alter the course of illness. Most types of anti-inflammatory drugs are effective. Individual responses and preferences should dictate which NSAIDS are used.

Systemic corticosteroids may be needed. Occasionally, glucocorticoid injections into affected joints or entheses using ultrasound guidance are helpful.

Disease modifying drugs (DMARDS) should be instituted as soon as possible. The drugs that have been most used include methotrexate and sulfasalazine.

More recently, biologic therapy has been shown to induce remission and these drugs should be employed earlier rather than later. Enbrel, Humira, Remicade, and Simponi are all effective.

Other biologic treatments are being studied.

Many clinicians use a combination of a DMARD such as sulfasalazine and a biologic to effect the best result.

Patients with eye involvement need to be treated aggressively. An opthalmologist should be consulted as soon as possible. Untreated eye inflammation can lead to blindness.

More information on drug therapy will be found in the treatment section.

Patients with advanced disease may require surgical intervention.

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