What’s Next for Ankylosing Spondylitis Treatment?

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What’s Next for Ankylosing Spondylitis Treatment?

By Abhijeet Danve, MD, as told to Hallie Levine

I have studied and treated ankylosing spondylitis (AS) for almost 10 years. It’s a form of axial spondyloarthritis (axSpA). That’s a type of inflammatory arthritis that primarily affects the spine and the sacroiliac (SI) joints that connect the lower spine to the pelvis. In its early stages, it’s called non-radiographic axSpA because its damage doesn’t usually show up yet on an X-ray. But in its late stage, when it does become apparent, it’s known as ankylosing spondylitis (AS).

Unfortunately, many people with AS go undiagnosed for 8-11 years. Up to 5% of patients with chronic back pain actually have AS or its earlier form, axSpA. But if you complain of back pain to your doctor, they usually just send you off for an X-ray of your lumbar spine, or lower back. This won’t help them spot the condition since the first signs are in your sacroiliac joints. And it can take up to 10 years for these changes to show up on conventional X-rays. There’s also a lack of awareness about this condition among doctors that treat back pain. As a result, we sometimes lose that window of opportunity to identify and treat people with AS at earlier stages.

Quicker Diagnosis

Thankfully, new guidelines were released about 10 years ago that allow us doctors to diagnose patients sooner. It’s now recommended that anyone with suspect axSpA and inconclusive X-rays have an MRI of their sacroiliac joints, too. It’s important to ask your doctor for a referral to a rheumatologist if you have chronic back pain that lasts for more than 3 months, starts gradually before the age of 45, is worse with rest, and improves with exercise. This is a specialist specifically trained to diagnose and treat inflammatory diseases that affect your joints and bones, like axSpA. They’ll screen you for other symptoms associated with this condition, including back pain that wakes you up in the middle of the night, heel or foot pain (plantar fasciitis), or inflammation in other parts of your body like your eyes (called iritis or uveitis), skin psoriasis, and intestinal inflammation (called Crohn’s disease). They can also order a blood test to screen for HLA-B27, a gene that raises your chances of getting axSpA. Remember, the earlier you get diagnosed, the more quickly you’ll be able to start treatments that can help improve symptoms, ease inflammation, and possibly prevent permanent joint damage.

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Notable Developments

Thankfully, we now have many excellent drugs available to treat both axSpA and AS. Almost half of all people respond well to nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and indomethacin. But if you don’t, there’s a whole class of drugs you can try known as tumor necrosis factor (TNF) blockers. When you have either condition, your body makes too many proteins called cytokines, which ramp up inflammation throughout your body. Over time, this is what causes joint and bone damage. The TNF blockers, given as injections, stop some of these cytokines.

For a long time, these were the only drugs available. But in the last several years, the FDA approved two new injectable drugs: ixekizumab (Taltz) and secukinumab (Cosentyx). They both block another type of inflammatory cytokine called interleukin-17, or IL-17. Normally, IL-17 helps your body defend itself against infections. But too much of it can cause joint inflammation, bone erosion, and bone fusion. These drugs target different cytokines than the TNF inhibitors, so the hope is that they can help those who haven’t gotten help from the TNF inhibitors.

There are studies underway to develop even more. There’s a new class of oral drugs, janus kinase (JAK) inhibitors, that show a lot of promise. These inhibitors block specific enzymes (JAK1, JAK2, and JAK3) that signal your cells to make more inflammation. One study found that people who took a JAK inhibitor for just over 3 months were twice as likely to have a strong response as those who took a placebo, or fake pill. Two drugs, tofacitinib and upadacitinib, are in clinical trials. We should know within the next year whether they get FDA approved.

There’s another class of medications called interleukin-23 inhibitors, like guselkumab and risankizumab, that are just as exciting. These target a cytokine known as interleukin-23 (IL-23) that also signals your cells to make more of another inflammatory cytokine, interleukin-17, or IL-17. When IL-23 is blocked, it stops the production of IL-17. This helps ease inflammation in your joints and lessens the chances of permanent damage.

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The Importance of Lifestyle Changes

While our treatments get better and better, I tell my patients they aren’t enough. Lifestyle is key when it comes to controlling symptoms and improving mobility. Daily range of motion and stretching exercises are particularly important. These improve flexibility and reduce stiffness, swelling, and pain. You’ll also need to exercise regularly, which includes strength and balance activities.  

I also stress to my patients that if they smoke, they need to quit. Smoking is bad for everyone’s health, but it’s particularly bad for people with inflammatory diseases like axSpA and AS. Research shows it can worsen symptoms like pain and mobility problems. People with axSpA and AS are also more likely to have depression or anxiety. It’s important to seek help, whether it’s through support groups or talk therapy. This can help you manage living with the disease.

WebMD Feature Reviewed by Michael W. Smith, MD on October 22, 2020

Sources

SOURCE: Abhijeet Danve, MD, Yale Medicine.

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