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Ankylosing spondylitis

  • It is a type of arthritis that attacks the spine and, in some people, the joints of the arms and legs. 
  • It can also involve the skin, intestines and eyes. The main symptom (what you feel) in most patients is low back pain. This occurs most often in axial spondyloarthritis. 
  • In a minority of patients, the major symptom is pain and swelling in the arms and legs. This type is known as peripheral spondyloarthritis. 
  • Many people with axial spondyloarthritis progress to having some degree of spinal fusion, known as ankylosing spondylitis. 

Diseases & Conditions

  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis/Reiter’s syndrome
  • Enteropathic arthritis
  • Undifferentiated: Patients with features of more than one disease who do not fit in the defined categories above

Ankylosing Spondylitis (AS) 

  • AS is a chronic, systemic, inflammatory disease of the joints and ligaments of the spine. Other joints may be involved. 
  • This typically results in pain and stiffness in the spine. 
  • The disease may be mild to severe. The bones of the spine may fuse over time causing a rigid spine. 
  • Early diagnosis and treatment may help control the symptoms and reduce debility and deformity. 

Who Gets Ankylosing Spondylitis (AS)? 

  • The onset is typically in late adolescence to early adulthood. It is rare for AS to begin after age 45. Ankylosing spondylitis tends to start in the teens and 20s and strikes males two to three times more often than females. 
  • Family members of affected people are at higher risk, depending partly on whether they inherited the HLA-B27 gene. 
  • The incidence is 1 in 1000 persons. About 90% of people with AS have the HLA B27 gene.

Cause

The cause of AS is unknown although there appears to be some genetic component. AS is associated with the HLA B27 gene but it is unclear why. The gene is seen in about 8% of normal Caucasians. There are no known infectious or environmental causes. The gut organisms may play a role in causing the disease.

Symptoms

  • Early on, there is pain and stiffness in the buttocks and low back due to sacroiliac joint involvement. 
  • Over time, the symptoms can progress up the spine to involve the low back, chest and neck. Ultimately, the bones may fuse together causing limited range of motion of the spine and limiting one’s mobility. 
  • Shoulders, hips and sometimes other joints may be involved. 
  • AS may affect tendons and ligaments. For example, the heel may be involved with Achilles
  • tendonitis and plantar fasciitis. 
  • Since it is a systemic disease, patients can get fever and fatigue, eye or bowel inflammation, and Rarely, there can be heart or lung involvement. 
  • AS is typically non life threatening. 
  • Usually, it is a slowly progressive disease. Most people are able to work and function normally.

Diagnosis

  • The diagnosis is typically suspected by the doctor based on the signs and symptoms. The doctor will take a thorough history and do a physical examination. 
  • Xrays, especially those of the sacroiliac joints and spine can be confirmatory. 
  • If X-rays do not show enough changes, but the symptoms are highly suspicious, your
  • doctor might order magnetic resonance imaging, or MRI, which shows these joints better and can pick up early involvement before an X-ray scan. 
  • The HLA B27 gene may be checked by a blood test, but its presence or absence does not ultimately confirm or reject the diagnosis.

Treatment plan

  • At this time there is no known curative treatment. 
  • Goals of treatment are to reduce pain and stiffness, slow progression of disease, prevent deformity, maintain posture and preserve function. 
  • Exercise programs are an essential part of the treatment. 
  • Patients may be referred for a formal physical therapy program. Patients with AS are given daily exercises for stretching and strengthening, deep breathing exercises and posture exercises to avoid stooping and slumping. Most recommended are exercises that promote spinal extension and mobility. 
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are traditionally used to control symptoms. There are many drug treatment options. The first lines of treatment are the NSAIDs, such as naproxen, ibuprofen, meloxicam or indomethacin. No one NSAID is superior to another. Given in the correct dose and duration, these drugs give great relief for most patients. 
  • Steroids, such as cortisone or prednisone, are rarely used, except for with injections to a tendon or joint. Sometimes, medications that are normally used for rheumatoid arthritis, such as sulfasalazine or methotrexate, may be used. These appear to be less helpful for the spine disease. 
  • Frequent exercise is essential to maintain joint and heart health. 
  • If you smoke, try to quit. Smoking aggravates spondyloarthritis and can speed up the rate of spinal fusion
  • TNF alpha blockers (a newer class of drugs known as biologics) are very effective in treating both the spinal and peripheral joint symptoms of spondyloarthritis. TNF alpha blockers that the FDA has approved for use in patients with ankylosing spondylitis are: 
  1. Infliximab (Remicade), which is given intravenously (by IV infusion) every 6-8 weeks at a dose of 5 mg/kg; 
  2. Etanercept (Enbrel), given by an injection of 50 mg under the skin once weekly; 
  3. Adalimumab (Humira), injected at a dose of 40 mg every other week under the skin; 
  4. Golimumab (Simponi), injected at a dose of 50 mg once a month under the skin. 
  • However, anti-TNF treatment is expensive and not without side effects, including an increased risk for serious infection. Biologics can cause patients with latent tuberculosis (no symptoms) to develop an active infection. 

Therefore, you and your doctor should weigh the benefits and risks when considering treatment with biologics. Those with arthritis in the knees, ankles, elbows, wrists, hands and feet should try DMARD therapy before anti-TNF treatment.

These drugs may not only help symptoms but also slow the progression of the disease. They are only given as IV’s in the doctor’s office or by self administered shots at home.

Pre-Post surgery care & advice

  • Surgical options are limited. 
  • Total hip replacement is very useful for those with hip pain and disability due to joint destruction from cartilage loss. 
  • Spinal surgery is rarely necessary, except for those with traumatic fractures (broken bones due to injury) or to correct excess flexion deformities of the neck, where the patient cannot straighten the neck.

Broader health impacts: Other problems can occur in patients with spondyloarthritis. 

  • Osteoporosis which occurs in up to half of patients with ankylosing spondylitis, especially in those whose spine is fused. Osteoporosis can raise the risk of spinal fracture. 
  • Inflammation of part of the eye called uveitis, which occurs in about 40% of those with spondyloarthritis. Symptoms of uveitis include redness and pain of the eye. Steroid eye drops most often are effective, though severe cases may need other treatments from an ophthalmologist. 
  • Inflammation of the aortic valve in the heart, which can occur over time in patients with spondylitis. 
  • Psoriasis, a patchy skin disease, which if severe will need treatment by a dermatologist. 
  • Intestinal inflammation, which may be so severe that it requires treatment by a gastroenterologist.

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