Medical Treatment of Ankylosing Spondylitis

Introduction:

Ankylosing spondylitis, classified as a variant of axial spondyloarthritis, impacts the axial skeletons, encompassing the spine, chest, and pelvis. These changes are visible on X-ray imaging. Remarkably, this condition can affect individuals under the age of 45. While the precise cause remains elusive, a noteworthy genetic factor called Human Leukocyte Antigen (HLA) B27 plays a significant role. The primary early indication of ankylosing spondylitis manifests as pain in the sacroiliac joint. This discourse will delve into this condition's diagnostic criteria and treatment guidelines.

What Is Ankylosing Spondylitis?

An enduring ailment, ankylosing spondylitis, influences the spine, encompassing the pelvis and limbs. This protracted condition often begets deformities and stiffness in the spine and hips, fostering a rigid walking posture. Notably, hip joints bear a greater brunt of damage compared to other joints. Accurate assessment stands paramount in the treatment of this affliction.

Furthermore, ankylosing spondylitis extends its reach beyond the skeletal domain, affecting various organs. This impact reverberates in patients' lives and manifests through symptoms such as dactylitis (swollen fingers), uveitis (inflamed eye), inflammatory bowel disease, and psoriasis (a skin disorder).

How to Diagnose Ankylosing Spondylitis?

Ankylosing spondylitis exhibits a higher prevalence in males than in females, and intriguingly, the manifestation of the disease differs significantly between the two genders. In the male population, the spine takes the brunt of the impact, while in females, the wrists, knees, and hips emerge as the primary areas of concern. Adding to the complexity, female patients often endure a prolonged diagnostic journey, with an average period of over 10 years from the initial onset of symptoms to receiving a conclusive diagnosis.

In the quest for early detection, the conventional modified New York criteria proved inadequate, necessitating a shift towards a more nuanced approach. Diagnosis now entails an assessment based on the Ankylosing Spondylitis Assessment (ASAS), acknowledging the limitations of previous methods. To capture a broader spectrum, axial spondyloarthritis has taken precedence over the singular focus on Ankylosing Spondylitis. This encompassing category involves conditions like psoriatic arthritis, reactive arthritis, spinal arthritis, and the prevalent ankylosing spondylitis. For individuals grappling with back pain persisting beyond three months and an age of onset surpassing 45 years, specific diagnostic criteria come into play, which include:

• Identifying unique findings in radiological assessments, such as X-rays or MRIs, coupled with manifesting a singular clinical symptom of axial spondyloarthritis.

or

• The presence of two clinical symptoms indicative of axial spondyloarthritis, alongside a positive result for the HLA-B27 genetic factor.

Axial spondyloarthritis manifests through a spectrum of distinctive features, encompassing arthritis, uveitis, psoriasis, colitis, inflammatory back pain, enthesitis, a familial background of axial spondyloarthritis, a favorable response to NSAIDs, a positive presence of the HLA-B27 genetic factor, and an elevation in CRP (C-reactive protein) levels.

What Is the Goal of Treating Ankylosing Spondylitis?

Ankylosing spondylitis, a condition impacting the spine, exhibits diverse progression among individuals, with approximately one-third facing the potential for disability. Early stages are characterized by stiffness, restricted chest expansion, back pain, and diminished spine mobility. The overarching goals are:

1. Alleviating discomfort and mitigating pain.

2. Facilitating the restoration of individuals' capacity to perform daily tasks and work-related activities.

3. Slowing down the progression of spinal damage that could result in physical limitations.

What Is the Medical Treatment of Ankylosing Spondylitis?

The medical treatment of ankylosing spondylitis includes:

1. Physical Therapy and Education: Effectively managing ankylosing spondylitis without relying solely on medication hinges on two pivotal factors: patient education and consistent exercise. Engaging in group physical therapy under appropriate supervision surpasses individual exercise efforts. Employing correct exercises not only aids in pain reduction but also contributes to maintaining joint flexibility.

2. Medications: This includes:

1. Nonsteroidal Anti-inflammatory Drugs(NSAIDs): COX-2 inhibitors stand as the primary pharmacological choice in the treatment of ankylosing spondylitis. Recent research underscores a correlation between ankylosing spondylitis and the PTGER4 gene (prostaglandin E receptor 4), instigating bone absorption. Consequently, NSAIDs intervene by blocking this process, curbing bone absorption. Continuous administration is recommended for optimal outcomes, notwithstanding potential complications tied to the gastrointestinal and cardiovascular systems. If there's a lack of improvement, considering medications such as TNF-α inhibitors becomes prudent.

2. Analgesics: When pain persists despite the use of NSAIDs and TNF-α inhibitors, alternative measures come into play. Analgesics such as Acetaminophen and other opioid analgesics are employed.

3. Glucocorticoids: Steroids can be administered directly into inflamed muscles for targeted relief. However, this practice is generally discouraged when considering application to the entire body.

4. Disease-Modifying Anti-Rheumatic Drugs (DMARDs): Axial disease management refrains from using DMARDs like Methotrexate and Sulfasalazine, which are instead directed toward addressing peripheral arthritis.

5. TNF-α Inhibitors: Biologics, aptly named for being derived from living cells, emerge as a notable category of drugs. Their efficacy extends beyond advanced stages to include early phases of disease. Indications for their use arise when more than two NSAIDs have been employed over four weeks without relief. Key members of this drug category encompass Etanercept, Infliximab, and Adalimumab. Several principles guide their application:

   • If one TNF-α inhibitor proves ineffective, substitution with another is a viable approach.

   • Monoclonal antibodies like Infliximab exhibit greater efficacy than receptor blockers such as Etanercept.

   • Assessment of responses to these biological agents should occur at least 12 weeks post-administration.

   • Enhanced results are plausible when short-duration symptoms and the C-reactive protein test yield positive results.

   • Before initiating TNF-α inhibitors, a crucial step involves screening for latent tuberculosis, as certain studies suggest an elevated risk of tuberculosis when these drugs are utilized.

3. Duration of Medications: Optimal management of ankylosing spondylitis involves continuous medication use, offering relief by impeding the formation of new bone. However, in specific situations, such as patients planning pregnancy, preparing for surgery, or encountering frequent infections, considerations may lead to the avoidance of certain medications like TNF-α inhibitors.

Conclusion:

The medical approach to Ankylosing Spondylitis (AS) unfolds as a multifaceted strategy, endeavoring to address symptoms, enhance functionality, and impede disease advancement. Nonsteroidal anti-inflammatory drugs (NSAIDs) persist as a fundamental element in symptom management. At the same time, the advent of biological therapies, notably TNF inhibitors, has brought about a revolutionary shift in AS management, providing substantial relief for many patients.