Understanding Ankylosing Spondylitis and Treatment Options
Ankylosing spondylitis (AS) is a type of inflammatory arthritis that primarily affects the spine and sacroiliac joints. Over time, chronic inflammation can cause bones to fuse together and lead to a rigid spine. While there is no cure, various treatments can help manage symptoms and slow progression of the disease.
Symptoms of Ankylosing Spondylitis
Some common signs and symptoms of AS include:
- Lower back pain and stiffness that is worse in the morning
- Neck pain and stiffness
- Fatigue
- Pain and swelling in joints besides the spine, such as the shoulders, hips, ribs, heels and small joints of the hands and feet
Symptoms typically begin slowly and progress over several years. They often start in late adolescence or early adulthood, with the average age of onset being 24 years old. However, onset can occur later as well.
Causes and Risk Factors for Ankylosing Spondylitis
The exact cause of AS is unknown. Research suggests genetics and environmental factors both play a role. Specific genetic markers like HLA-B27 are linked to AS. However having this marker does not mean someone will necessarily develop the disease. Other potential factors include:
- A family history of AS
- Age (AS usually develops in young adulthood)
- Being born male (AS is 2-3 times more likely to affect men)
- Having a preceding infection such as a gastrointestinal or genitourinary infection
Treatment Goals and Medication Options
While there is no known cure for ankylosing spondylitis, various treatments can help manage symptoms and progression. The main goals are to:
- Reduce inflammation and pain
- Preserve mobility and flexibility
- Maintain proper posture and spinal function
- Improve physical function for activities of daily living
- Decrease disease complications
Medications, physical therapy, exercise, and sometimes surgery are key components of a comprehensive treatment plan. Medications may include:
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs like ibuprofen are frequently used as a first-line drug for AS. They help relieve swelling, pain and stiffness without the serious side effects of stronger medications. However, they may cause stomach upset or bleeding in some people.
Disease-Modifying Antirheumatic Drugs (DMARDs)
The most commonly used DMARD for ankylosing spondylitis is sulfasalazine, especially if peripheral joints are affected. DMARDs suppress the immune system to reduce inflammation. Methotrexate may sometimes be used as well.
Biologics
Biologics like tumor necrosis factor (TNF) inhibitors are often prescribed for those with active AS who do not improve sufficiently with NSAIDs. TNF inhibitors help block a protein involved with inflammation. Examples are etanercept, infliximab, adalimumab and golimumab.
Corticosteroids
Corticosteroids like prednisone are powerful anti-inflammatories. Because they can have severe long-term side effects, doctors usually do not prescribe oral steroids for extended use with AS. However, a short course may help relieve a severe flare.
Pain Medications
Over-the-counter pain relievers like acetaminophen or prescription medications may be options for pain control. These are often used in conjunction with anti-inflammatories.
Methotrexate for Treatment of Ankylosing Spondylitis
Methotrexate is sometimes used to treat active ankylosing spondylitis, especially if multiple peripheral joints are inflamed. It can be taken orally once a week, often starting at 7.5 milligrams and increased gradually as tolerated up to 25 mg if symptoms continue.
How Methotrexate May Help with AS
As an immunosuppressant DMARD, methotrexate works by decreasing activity of the immune system to reduce pain and swelling. Though the exact mechanism is unknown, its theorized to work in a few ways:
- Blocks enzymes involved with immune activation and inflammation
- Decreases production of immune cells and autoantibodies causing inflammation
- Changes effects of other chemicals that regulate the immune response
Studies indicate continued use shows sustained benefit for many AS patients. One trial found over half of participants taking methotrexate for 1 year had a 50% improvement in symptoms compared to placebo. It may also help prevent bone changes like syndesmophyte formation that occur with increased inflammation.
Potential Benefits
Possible advantages of using methotrexate for ankylosing spondylitis include:
- Effective at easing inflammation, pain and stiffness
- Can treat peripheral arthritis symptoms as well
- Weekly oral dosing is convenient
- Less costly than biologics
- May slow AS radiographic progression and bone changes when taken continuously
Risks and Side Effects
As with most medications, methotrexate does come with some risks:
- Upset stomach, diarrhea or mouth sores
- Headaches, fatigue and dizziness
- Decreased white blood cell count
- Nausea or vomiting
- Increased liver enzymes
- Hair thinning or hair loss
Because it suppresses the immune system, people taking it are also more prone to infections.close monitoring with blood work is needed to check for side effects. Taking folic acid helps reduce adverse effects. Anyone with liver/kidney issues, blood disorders or active infections should avoid methotrexate.
Combination Therapy
Doctors sometimes prescribe methotrexate together with TNF inhibitors or NSAIDs. Using different classes of medications that work in distinct ways may enhance efficacy. The synergistic effects allow lower doses of each individual drug to be taken, minimizing side effects.
The Importance of a Multidisciplinary Approach
Medication is a pivotal aspect of AS treatment. However, a holistic plan also encompassing physical therapy, home exercises, joint protection advice, posture training, weight management and even surgery maximizes positive outcomes. All these modalities together aim to relieve pain, maintain range of motion and flexibility, prevent deformities, and help patients function optimally at work, home, and leisure.
Finding the Right Treatment Plan for You
Ultimately the best medicine for ankylosing spondylitis depends on someones specific symptoms, disease severity, response to therapy and tolerance of side effects. Starting medication rapidly at the first signs of persistent lower back pain or spinal inflammation offers the best chance to alter the disease course. Close provider supervision helps tailor and optimize treatment for each individual. Being proactive with a multidisciplinary approach provides the greatest possibility of remission.
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.
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