Using Methotrexate to Treat Ankylosing Spondylitis - Benefits and Risks

Using Methotrexate to Treat Ankylosing Spondylitis

Ankylosing spondylitis (AS) is an inflammatory autoimmune disease that mainly affects the spine and sacroiliac joints. Joint damage can eventually cause chronic pain, fusion and loss of mobility. While there is no cure, certain medications offer significant relief.

Methotrexate is one medication that is sometimes used to manage inflammation and joint symptoms associated with AS. But how effective is it and what should you know before considering methotrexate treatment?

Understanding Ankylosing Spondylitis

AS causes immune-mediated inflammation in the axial skeleton, primarily the spine and pelvis. This can progress to bone erosion, calcium deposits along ligaments and eventual fusion of vertebrae or sacroiliac joints.

In addition to back and neck stiffness and pain, other symptoms include:

• Hip, shoulder and ribcage discomfort
• Fatigue and loss of appetite
• Fevers or nausea
• Eye inflammation
• Lung, bowel or heart complications (rare)

Onset often occurs in a person's 20s and 30s. AS cannot be cured but early effective treatment helps minimize irreversible joint damage. Let's take a closer look at how methotrexate may help.

How Methotrexate Works for Ankylosing Spondylitis

Methotrexate belongs to a class of medications known as disease-modifying antirheumatic drugs (DMARDs). It has immunosuppressive properties from inhibiting key enzymes involved in the rapid division of inflammatory cells.

Specifically within joints, methotrexate may improve AS symptoms by:

• Suppressing overactive immune function
• Reducing swelling and stiffness
• Slowing or preventing bone and cartilage deterioration

Unlike stronger biologic medications, methotrexate is usually not powerful enough to induce disease remission on its own. But it can enhance quality of life when added to NSAIDs, physiotherapy and exercise.

Benefits of Methotrexate for Ankylosing Spondylitis

When standard treatments no longer adequately control AS progression and associated pain, adding methotrexate may offer certain advantages:

• Decreases spinal and joint inflammation
• Lessens morning stiffness duration
• Improves mobility and physical function
• Allows lower NSAID dosage
• Delays spine fusion when started early
• Inexpensive compared to biologics

Studies analyzing methotrexate in AS patients demonstrate modest improvements in disease activity scores, less evidence of active inflammation on scans and better quality of life measures.

Potential Risks and Side Effects

Methotrexate can cause a variety of side effects ranging from nuisance to serious. Working closely with your rheumatologist allows quick intervention for any problems.

Common issues include:

• Nausea, vomiting, diarrhea
• Fatigue
• Headaches, dizziness
• Mouth sores
• Skin rash, itching

Rare but dangerous reactions involve bone marrow, kidney, lung or liver toxicity. Your doctor will monitor bloodwork and may prescribe folic acid to mitigate risks.

Who Should Consider Methotrexate for Ankylosing Spondylitis?

Methotrexate works well for certain AS patients depending on individual factors. Review this checklist with your rheumatologist:

Failed First Line Treatment

If maximizing NSAIDs, physical therapy, and home exercise no longer keeps your AS symptoms under control, adding methotrexate may help rein inflammation back in.

High Disease Activity

Baseline testing quantifies AS disease activity through inflammatory markers, functional scores and imaging. Those with high scores despite standard treatment may benefit from methotrexate’s immunosuppression.

Early Stage Progression

Initiating methotrexate within the first 10 years after onset shows most success delaying rapid spinal bone formation. This helps retain flexibility and range of motion longer.

Cannot Tolerate Biologics

For patients unable to use biologics like TNF inhibitors due to side effects, cost or other issues, methotrexate serves as an alternative extra line of defense.

Desire to Delay Biologics

Younger AS patients sometimes opt to start with methotrexate first before progressing to specialty shots or infusions to postpone dealing with stronger immunosuppression risks as long as possible.

What to Expect When Taking Methotrexate

If you and your doctor determine adding low dose methotrexate could benefit your AS, discuss what the treatment schedule entails and what monitoring requires.

Weekly Dosing

Methotrexate is taken orally or by injection once weekly, usually split into two smaller doses 12 hours apart. This allows the body to better clear the medication between doses to reduce side effects.

Folic Acid Protocol

Taking folic acid or folinic acid 24 hours after your weekly methotrexate is common. Theseflood the body with usable folate to minimize adverse reactions involving red and white blood cells, gut, hair and liver.

Lab Monitoring

Expect bloodwork testing at baseline before starting, twice monthly at first, then every 1 to 3 months subsequently. This checks for lowered blood counts signaling bone marrow suppression or elevated liver enzymes indicating toxicity.

Your rheumatologist may periodically order bone scans or CTs to track whether methotrexate slows spinal damage as intended.

Timeline for Improvement

Patience is necessary when beginning methotrexate, as dose titration and loading can take 6 to 12 weeks until therapeutic levels build adequate anti-inflammatory effect. Symptoms may initially worsen before improving.

The Bottom Line

Though not considered a first line of defense, methotrexate can serve as a beneficial add-on treatment for ankylosing spondylitis patients experiencing insufficient relief from standard therapies. It may help delay rapid spinal fusion as well.

Of course, methotrexate does not come without side effect risks and commitment to careful monitoring. Discussing with your rheumatologist whether potential benefits could outweigh the required precautions for your situation is key to determining if a methotrexate trial makes sense.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.