treatment of ankylosing spondylitis

There is no cure for ankylosing spondylitis (AS). Treatment aims to relieve symptoms and slow the process of the spine stiffening.

Physiotherapy

Keeping active can improve your posture and your range of spinal movement, as well as preventing your spine from becoming stiff and painful.

As well as keeping active, physiotherapy is a key part of treating ankylosing spondylitis. A physiotherapist (a healthcare professional  trained in using physical methods of treatment) can advise about the most effective exercises and draw up an exercise programme suitable for you.

Types of physiotherapy recommended for ankylosing spondylitis include:

• a group exercise programme, where you exercise with others
• an individual exercise programme – you are given exercises to do by yourself
• massage – your muscles and other soft tissues are manipulated to relieve pain and improve movement (the bones of the spine should never be manipulated as this can cause injury in people with ankylosing spondylitis)
• hydrotherapy – exercise in water (usually a warm, shallow swimming pool or a special hydrotherapy bath); the weight of the water helps improve your circulation (blood flow), relieve pain and relax your muscles
• electrotherapy – electric currents or impulses (small electric shocks) make your muscles contract (tighten), which can help ease pain and promote healing

Some people prefer to swim or play sport to keep flexible. This is usually fine, although some daily stretching and exercise is also important (see below).

Exercise

The National Ankylosing Spondylitis Society (NASS) provides detailed information about different types of exercise to help you manage your condition.

However, if you are in doubt, speak to your physiotherapist or rheumatologist before taking up a new form of exercise or sport.

Alongside physiotherapy, you will also probably be prescribed medication, such as:

• painkillers
• tumour necrosis factor (TNF) blockers
• bisphosphonates
• disease-modifying anti-rheumatic drugs (DMARDs)
• corticosteroids

These are described below.

Painkillers

You may need painkillers to manage your condition while you are being referred to a rheumatologist. The rheumatologist may continue prescribing painkillers, although not everyone needs them, at least not all the time. The first type of painkiller usually prescribed is a non-steroidal anti-inflammatory drug (NSAID).

Non-steroidal anti-inflammatory drugs (NSAIDs)

As well as helping to ease pain, non-steroidal anti-inflammatory drugs (NSAIDs) help relieve inflammation (swelling) in your joints. Examples of NSAIDs include:

• ibuprofen
• naproxen
• diclofenac

When prescribing NSAIDs, your GP or rheumatologist will try to find the one that suits you best and the lowest possible dose that relieves your symptoms. Your dose will be monitored and reviewed as necessary.

Paracetamol

If NSAIDs are unsuitable for you, an alternative painkiller, such as paracetamol, may be recommended.

Paracetamol rarely causes side effects and can be used in women who are pregnant or breastfeeding. However, paracetamol may not be suitable for people with liver problems or those dependent on alcohol (have an alcohol addiction).

Codeine

If necessary, as well as paracetamol, you may also be prescribed a stronger type of painkiller called codeine. Codeine can cause side effects including:

• nausea (feeling sick)
• vomiting (being sick)
• constipation (an inability to empty your bowels)
• drowsiness, which could affect your ability to drive

Tumour necrosis factor (TNF) blocker

If your symptoms cannot be controlled using painkillers or exercising and stretching, a tumour necrosis factor (TNF) blocker may be recommended. TNF is a chemical produced by cells when tissue is inflamed.

TNF blockers are given by injection and work by preventing the effects of TNF. This helps reduce inflammation in your joints caused by ankylosing spondylitis. Examples of TNF blockers include:

• adalimumab
• etanercept
• golimumab

TNF alpha blockers are a relatively new form of treatment for ankylosing spondylitis, and their long-term effects are unknown. However, research into the use of TNF blockers for treating rheumatoid arthritis is providing clearer information about their long-term safety.

If your rheumatologist recommends using TNF blockers, the decision about whether they are right for you must be discussed carefully and your progress will be closely monitored. This is because TNF blockers interfere with the immune system (the body’s natural defence system).

NICE guidelines

The National Institute for Health and Clinical Excellence (NICE) has produced guidance about the use of these TNF blockers. NICE states that adalimumab, etanercept and golimumab may only be used if:

• your diagnosis of ankylosing spondylitis has been confirmed
• your level of pain is assessed twice (using a simple scale that you fill in) 12 weeks apart and confirms your condition is still active (has not improved)
• your Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is tested twice, 12 weeks apart, and confirms your condition is still active (BASDAI is a set of measures devised by experts to evaluate your condition by asking a number of questions about your symptoms)
• treatment with two or more NSAIDs for four weeks at the highest possible dose has not controlled your symptoms

After 12 weeks of treatment with TNF blockers, your pain score and BASDAI will be tested again to see whether they have improved sufficiently to make continued treatment worthwhile for you. If they have, treatment will continue and you will be tested every 12 weeks.

If there is not enough improvement after 12 weeks, you will be tested again at a later date or the treatment will be stopped.

Infliximab is an alternative TNF blocker that may be used to treat ankylosing spondylitis. However, it is not recommended by NICE. If you are currently taking infliximab, you should continue to do so until you and your rheumatologist decide it is appropriate for you to stop.

Other new TNF blockers and similar medications are being developed and may be approved by NICE.

Bisphosphonates

Bisphosphonates are usually used to treat osteoporosis (weak and brittle bones), which can sometimes develop as a complication of ankylosing spondylitis. Bisphosphonates may also be effective in treating ankylosing spondylitis, although the evidence is not entirely clear. They may also be used if you have osteoporosis.

Bisphosphonates can be taken by mouth (orally) as tablets or given by injection.

Disease-modifying anti-rheumatic drugs (DMARDs)

Disease-modifying anti-rheumatic drugs (DMARDs) are an alternative type of medication often used to treat other types of arthritis. DMARDs may be prescribed for ankylosing spondylitis, although they are only beneficial if peripheral joints are involved rather than the spine.

Two DMARDs found helpful for inflammation of joints other than the spine include:

• sulfasalazine
• methotrexate

Corticosteroids

Corticosteroid medicines (steroids) have a powerful anti-inflammatory effect and can be taken in various ways, for example as:

• tablets (oral)
• injections (parenteral)

If a particular joint is inflamed, corticosteroids can be injected directly into the joint. After the injection you will need to rest the joint for up to 48 hours (two days). It is usually considered wise to have a corticosteroid injection up to three times in one year, with at least three months between injections in the same joint. This is because corticosteroids injections can cause a number of side effects, such as:

• infection in response to the injection
• the skin around the injection may change colour (depigmentation)
• the surrounding tissue may waste away
• a tendon (cord of tissue that connects muscles to bones) near the joint may rupture (burst)

Corticosteroids may also help to calm down painful swollen joints when taken as tablets. Occasionally, when pain and stiffness are severe, corticosteroids can be very helpful when given as an injection into your muscle (intramuscular injection).