Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line medications for ankylosing spondylitis (AS). These medications include indomethacin, naproxen, ibuprofen, diclofenac, and meloxicam.
Another class of NSAIDs called COX-2 inhibitors may help prevent the gastrointestinal side effects that result from some common NSAIDs. One example of a COX-2 inhibitor is celecoxib (Celebrex).
Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate and sulfasalazine, have also shown some efficacy in treating AS.
The characteristic signs and symptoms of AS include pain, stiffness, and decreased mobility of the spine, sacroiliac joints, and pelvic joints.
However, early symptoms may also occur in the ribs, shoulders, and tendons of the feet and ankles. These may result in pain and inflammation. In some cases, a first-line treatment for these areas is a local injection of corticosteroids.
Biologics are medications derived from living organisms — such as humans, animals, and microorganisms — that treat rheumatologic and other inflammatory conditions.
Biologics available to treat AS include tumor necrosis factor (TNF) inhibitors. The Food and Drug Administration (FDA) approved the earliest TNF inhibitor, called etanercept (Enbrel), in 2003.
Other TNF inhibitors available to treat AS include adalimumab (Humira), certolizumab (Cimzia), golimumab (Simponi), and infliximab (Remicade).
Biologics called IL-17 inhibitors can also treat AS. These include secukinumab (Cosentyx) and ixekizumab (Taltz).
NSAIDs and biologics work by inhibiting mediators of inflammation.
Specifically, NSAIDs act by blocking the synthesis and release of prostaglandins, which are lipid compounds that cause inflammation.
Biologics target more specific inflammatory pathways to interfere with the production of chemicals and proteins, such as cytokines. These can contribute to immune and inflammatory responses in the body.
The most common side effects of NSAID treatment involve the gastrointestinal tract. They may include gastritis, ulcers, bleeding, and heartburn. That said, following the prescribed dosing schedule and taking medications with food can alleviate some of these symptoms.
A doctor may also prescribe antacids or preparations such as sucralfate (Carafate) to protect the gastrointestinal tract. Also, a person should not take NSAIDs with aspirin.
The short-term use of proton pump inhibitors, such as omeprazole, has proven to be helpful in some people.
Those with existing heart disease have a high risk of experiencing a heart attack or stroke while taking NSAIDs. Health professionals have also reported these risks in people without cardiovascular disease.
The most significant risk associated with taking biologics or DMARDs is that a person may develop an infection, as these agents can alter immune system responses. Specific risks include the reactivation of tuberculosis or hepatitis. A doctor should screen for these infections before prescribing any biologic or DMARD.
In some cases, biologics have caused heart failure, central nervous system problems, and visual changes, as well as lupus-like syndromes with rash and joint inflammation.
A doctor may recommend surgery for people with AS when they have:
- severe, intractable pain
- a loss of mobility
- structural irregularities, due to fusion of the joints
- compression of the nerve roots
Preserving range of motion and flexibility is essential in the management of AS. Early on, a doctor should also recommend physical therapy. Engaging in daily stretching exercises, adjusting sleeping positions, and making walking and posture modifications are all important changes to consider.
Although more research will be necessary to determine the efficacy of complementary treatments for AS, the following therapies have been beneficial for some people:
- careful massage therapy
- acupuncture
- yoga
- transcutaneous electrical nerve stimulation
Without early or proper treatment, the following complications can occur:
- chronic pain and stiffness
- irregularities in the spine and axial skeletal joints
- fusion of the joints
- limited mobility and function
- osteoporosis
- nerve compression
- inflammation of the eyes
- inflammation of the heart and aorta
- difficulty breathing due to decreased lung expansion
There are also some reports of people developing a restrictive lung disease with fibrosis and cyst formation.
There are several medications in the pipeline that are currently undergoing clinical trials to test their safety and efficacy for treating AS.
One of these is tofacitinib (Xeljanz), an oral medication with approval to treat rheumatoid arthritis, psoriatic arthritis (PsA), and ulcerative colitis. It is an immunosuppressive that blocks enzymes that play a role in inflammation.
Filgotinib is an enzyme inhibitor undergoing a second phase III trial to assess its safety and efficacy in AS. Bimekizumab, another drug that targets cytokines, is also in a phase III trial.
Research into the genes involved in the expression of AS is ongoing and include a gene called ERAP1. This gene is important because of its association with HLA-B27, which is present in many people with AS.
A significant percentage of people with AS have subclinical bowel inflammation. Research into the connection between AS and inflammatory bowel disease is also ongoing.
Ustekinumab (Stelara), an IL-23 and IL-12 inhibitor, is already indicated to treat Crohn’s disease, ulcerative colitis, psoriasis, and PsA. More research is necessary to determine whether or not it can also treat AS.
Health professionals do not know for sure if there will ever be a cure for AS. However, most people with AS can lead long, productive lives.
Because of the time lag between the symptoms of axial disease and radiographic confirmation of the condition, it is essential to focus on early diagnosis.
Experts have developed new criteria for nonradiographic axial spondyloarthropathies to evaluate people with spine pain and inflammation.
The criteria include:
- male sex
- HLA-B27 positivity
- smoking
- higher baseline C-reactive protein
- the extent of MRI evidence of inflammation
- younger age of onset
Using these criteria could help lead to earlier diagnoses, more appropriate therapy, and the prevention of complications.
Brenda B. Spriggs, M.D., MPH, FACP, is a clinical professor emerita at the University of California, San Francisco, a rheumatology consultant for several healthcare organizations, and an author. Her interests include patient advocacy, and she is passionate about providing expert rheumatology consultation to physicians and underserved populations. She is a co-author of Focus on Your Best Health: Smart Guide to the Health Care You Deserve.