Let's Talk About Treatment for Ankylosing Spondylitis
Having a chronic illness can be a tough adjustment—but managing the pain doesn't have to be. With AS, you've got plenty of treatment options.
If you’re here, you’re hurting, and that’s no good. Even though there’s no cure for ankylosing spondylitis (AS), there are highly effective treatments available, with more on the horizon. And, here’s something surprising: One of the best remedies may very well be the simplest, the cheapest, and the safest. Curious? Read on to learn more about a lifestyle change that can make a real difference, plus what you need to know about breakthrough biologics and how you can avoid ever needing surgery. We’ve got you.
Our Pro Panel
We went to some of the nation's top experts on ankylosing spondylitis to bring you the most up-to-date information possible:
Anca Askanase, M.D.
Rheumatologist, Director of Rheumatology Clinical Trials
Columbia University Medical Center
New York City
Howard Blumstein, M.D.
Rheumatologist, Clinical Professor of Medicine
Stony Brook University
Jonathan Greer, M.D.
Rheumatologist, Assistant Clinical Professor of Medicine
University of Miami
Palm Beach, FL
No! Chiropractors may provide relief for other types of backache, but their treatment is not appropriate for AS. In fact, they can make things worse. The decreased flexibility of the spine makes anyone with ankylosing spondylitis highly prone to spinal fracture, so the hands-on adjustments chiropractors make is not recommended.
The best we can say right now is maybe. Some studies suggest that they do not, while others have shown that they can reduce the progression of spinal damage seen on an X-ray by as much as 50%.
Yes! The right kinds of exercise go a long way towards both relieving pain and stiffness and maintaining flexibility in your spine and other affected joints. For many AS patients with mild to moderate symptoms, exercise and using NSAIDs as needed are effective treatments.
That’s perfectly okay. You should adjust your routine, focusing on your stretching exercises to maintain your range of motion and do light aerobic activity, such as a short walk. Hold off on strength and balance exercises, as well as more intense aerobics or sports, if they worsen your symptoms.
What Is AS, Anyway?
Let’s review: You know that osteoarthritis causes pain and stiffness in the joints of older people due to wear and tear.
Ankylosing spondylitis (pronounced ank-eye-low-sing spon-dill-eye-tiss) is different: It's a form of inflammatory arthritis that strikes at much younger ages, typically between 17 and 45 years of age. The hallmark characteristic is chronic inflammation in the sacroiliac (SI) joints, which join the spine to the pelvis. Although AS primarily affects the spine, other areas can become inflamed as well, including the shoulders, hips, ribs, heels, and small joints of the hands and feet, and it can lead to severe, chronic pain and discomfort. In more advanced cases, this inflammation can lead to ankylosis—new bone formation in the spine—causing sections to fuse into a fixed, immobile position.
You may not have heard of AS until now, but the condition is not that uncommon. About 1 out of every 200 adults in the U.S., or 1.1 million people, has AS, according to The Spondylitis Association of America. Once considered primarily a male disease, there is increasing evidence that women may be underdiagnosed and the true ratio of men to women might be closer to 1:1.
What Are the Best AS Treatments?
Ankylosing spondylitis is a not your usual chronic disorder because one of the first-line treatments isn’t a serious drug or surgery.
In fact, this remedy would be considered a complementary therapy for pretty much every other lifelong illness on the planet. We’re talking about good old-fashioned exercise, folks, and the benefits of breaking a sweat to AS patients are vast.
What’s more, there’s a good chance that another first-line treatment is already sitting in your medicine cabinet, no prescription required. That would be nonsteroidal anti-inflammatory meds, otherwise known as NSAIDs. (You know them as aspirin, Aleve (naproxen), and Advil or Motrin (ibuprofen.) It’s not unusual for AS patients to manage on just these two “treatments” for years. Here’s the lowdown on how and why they work, and what you need to know when it’s time to move on to other medication options like biologics.
It's a no-brainer that moving your body and getting your blood pumping is good for everyone. Exercise increases strength, endurance, balance, and flexibility. It also improves cardiovascular endurance, reduces high blood pressure, increases good cholesterol (HDL), maximizes bone density, helps in weight management, lowers stress levels, boosts self-esteem, and even has the potential to better the body’s response to medications.
AS patients can add even more to this mega-list of benefits: Exercise loosens up the joints, relieves pain and stiffness, and keeps the spine flexible, while also improving posture, fatigue, and breathing capacity. It’s not a stretch to say exercise will improve your overall function and quality of life.
Huge, right? But before you get nervous about having to train for a marathon, know this: We’re not talking extreme exercise, which isn’t great for people with AS, either. We’re going for a gentler approach here. You’ll need to avoid anything high-impact (running, jumping rope) or risky (black-diamond ski runs). Instead, your routine should include these important exercise components:
Stretching: These exercises should be done daily to take the muscles and joints through their full range of motion. Think neck, side, and hamstring stretches, or even the warm-up type of exercises you’d do before playing a sport. Yoga, too, is great for AS. Those downward dogs can do wonders for the lower back.
Strengthening: You can use weights, resistance bands, or just your own bodyweight to build muscle. Think: sit-ups, planks, hip and leg extensions, and Pilates. It’s especially important to focus on strengthening your core muscles in your abdomen and back because they support the spine, reducing the stress on it and minimizing back pain. Aim for two to four times a week.
Balance: This type of exercise should be done three to five times a week to reduce your chances of falling, which is especially important because people with AS have lower bone density and are at increased risk for fractures. Balance moves include single-leg stands, standing up from a chair without using your hands, or standing with one foot in front of the other with your toes touching your heel. The ancient Chinese tradition of Tai Chi also promotes better balance, reduces stress, improves mood, and even helps you sleep better.(You can also try this balance workout.)
Cardiovascular activity: Low-impact aerobic activities should be performed for a sustained period of time to increase blood flow to the heart and improve heart and lung function. Swimming, cycling, or using an elliptical trainer are all good options. Also: plain, old walking. Cardio exercise should be done three to five times per week for a total of at least 75 to 150 minutes each week.
Timing is also important. You’re going to need to get moving as soon as you can in the day to loosen up those screaming joints, but you still need to take a gradual approach.
Where to start? Gentle stretching is your best bet, followed by other types of exercise later in the day when you feel better. Ask your doctor about prescribing physical therapy when you’re first diagnosed to help you learn the most effective exercises and proper techniques, as well as ways to improve your posture.
If your posture is poor and your spine begins to fuse, there’s a risk that it will do so in a stooped position—almost as if you’re bending over or forward—which can increase your risk of complications including breathing or cardiovascular problems. But again, building your overall strength and flexibility will go far in helping you prevent complications like this.
Nonsteroidal Anti-inflammatories (NSAIDs)
These easily available and inexpensive meds work by blocking prostaglandins, a substance in the body that increases inflammation and pain. They have a proven track record in treating AS.
Over-the-counter options such as ibuprofen, naproxen, and aspirin may be all you need early on—along with exercise, of course—and many patients with milder symptoms are able to utilize them periodically for years before having to move to something else. No one type of NSAID is believed to be better than another for AS, so whichever one works best for you is fine.
While taking NSAIDs on an as-needed basis is usually best, most people with AS do need to take them regularly—but always as directed by a doctor, as overuse of NSAIDs can sometimes cause, liver, kidney, and gastrointestinal problems. Another important caveat: If you have AS with IBD—known as enteropathic arthritis—you should definitely not take NSAIDS (unless your doctor specifically directs you to take them) because they can aggravate IBD symptoms.
It’s not uncommon to need prescription-strength doses of NSAIDs for relief, which means side effects are more likely. The most typical side effects are stomach upset and gastrointestinal issues because NSAIDs can reduce the amount of protective mucus in the stomach, resulting in irritation. Eventually, heartburn, gastritis, ulcers, and bleeding in the digestive tract can occur. Talk to your doctor ASAP if you experience any side effects.
Other OTC meds such as antacids and acid reducers may help protect you and reduce your symptoms but talk with your doctor about which ones are appropriate.
One type of acid reducer you should avoid unless directed by your doctor is a proton-pump inhibitor (PPI) such as Prevacid (lansoprazole) and Prilosec (omeprazole). PPIs have been associated with an increased risk of osteoporosis because they reduce calcium absorption. This is a problem you definitely don’t need with your already compromised bone density. Another class of NSAID, known as COX-2 inhibitors—which includes the medication Celebrex (Celecoxib)—may reduce the risk of these GI side effects.
These groundbreaking meds are made from living microorganisms, plants, and animal cells, and they're delivered via injection (which you can learn to do yourself at home) or IV infusion at your doctor’s office.
When NSAIDs and exercise are not effective enough to control your symptoms, or the side effects of NSAIDs become too severe, your doctor will likely turn to this class of medication. You may be prescribed a biosimilar, which is a less expensive version that works the same way, similar to a generic medication. There are two main types of biologics (and biosimilars) used to treat AS:
Tumor-Necrosis Factor inhibitors (TNFi)
Also known as anti-TNF agents, these drugs work by binding to and putting the brakes on an inflammation-causing protein known as tumor-necrosis factor alpha (TNF-a). The TNFi biologics approved to treat AS include:
Cimzia (certolizumab pegol): Nearly 6 in 10 AS patients saw reduced inflammation by 12 weeks, with some showing improved symptoms by one to two weeks. Cimzia injections are needed every four weeks.
Enbrel (etanercept): Enbrel was the first biologic approved by the FDA to treat AS in 2003. It has been shown to be effective in three out of five adults after six months of use. Inflammation reduction was reported at two weeks in 46% of patients, and 59% saw benefits within eight weeks. Enbrel injections are needed weekly.
Humira (adalimumab): Reduced inflammation has been seen by some patients as early as two weeks, with 58% of patients seeing at least a 20% improvement after three months of use. Humira injections are required every other week.
Remicade (infliximab): About 60% of patients see an improvement in symptoms after six months on Remicade. Infusions are given in three starter injections at 0, 2, and 6 weeks, then as a maintenance dose every six weeks
Simponi/Simponi Aria (golimumab): More than 73% of patients experience at least a 20% reduction of inflammatory symptoms by 16 weeks. Simponi injections are required every four weeks; Simponi Aria is given as a baseline dose, followed by a second one at four weeks, then every eight weeks thereafter.
If a TNFi is not effective, or you can’t tolerate the side effects (more on these below), your next option is known as an IL-17 inhibitor. They work in the same way as TNFi biologics, but target a different inflammatory protein known as interleukin-17. The two approved for treating AS are:
Cosentyx (secukinumab): More than 60% of people saw at least a 20% improvement in AS symptoms by 16 weeks. An injection is needed every four weeks.
Taltz (ixekizumab): The most recent FDA-approved biologic for AS, Taltz has been shown to significantly improve inflammatory symptoms in 48% of patients by 16 weeks. Taltz is given as a two-injection starter dose the first time, then one injection is required every four weeks.
Side Effects and Safety
All types of biologics suppress your immune system, so an increased risk of infection may be the biggest side effect you could experience. If you carry a dormant infection, such as tuberculosis or Hepatitis B, it may also become reactivated when you take a biologic.
You’ll need to be tested for both of these infections before starting treatment, and stay up-to-date on all necessary vaccines, including an annual flu shot. IL-17 inhibitors have also been shown to exacerbate IBD symptoms associated with ulcerative colitis and Crohn's, or bring on new cases of IBD, so they are not appropriate for people with enteropathic arthritis.
Be sure to discuss these and any other health issues you may have with your rheumatologist. Your doctor can determine if the benefits of biologics outweigh the risks for you.
While they vary by biologic, other side effects may include:
Swelling at site of injection
Rarely, biologics—especially TNFis—may increase your risk of:
Other forms of arthritis
Lupus-like reaction that includes rash, joint pain, muscle ache and fever
There is no question that this class of medication, known as steroids for short, is an effective pain reliever. Unfortunately, oral steroids such as prednisone have systemic side effects that can be severe if they’re used long term, meaning more than three consecutive months at a time. For this reason, steroids are generally given as an injection directly into inflamed joints to treat AS. Steroids are not typically injected into the spine, however, so this treatment is used in AS when those peripheral joints (shoulders, knees, heels) are being affected.
One Last Note About Two Other AS Meds
Although neither is particularly effective at treating spinal arthritis, you may encounter two older drugs during your AS journey.
The first is sulfasalazine (brand name Azulfidine) and the other is the chemotherapy drug methotrexate (brand name Rheumatrex).
Both limit tissue damage from inflammation, but the Spondylitis Association of America only recommends their use when a biologic is not available (perhaps due to cost) or has lost its effectiveness over time. That said, methotrexate can help relieve inflammation in other parts of the body, including the eyes, and it can help biologics maintain their oomph by preventing the development of antibodies that interfere with how the drugs work.
Surgery for AS
Don’t stress about having to go under the knife eventually—odds are you won’t. In all but the most extreme situations, spinal surgery is not used to treat AS because it’s such a high-risk procedure.
Only when AS restricts breathing (rare!) is surgery performed to straighten a spine that has curved forward. In these situations, the surgeon will cut through the vertbrae and reposition them into a straighter, more vertical position.
Medically designed metal (usually titanium) rods, bars, wires, and screws are used to hold the repaired spine in place—usually permanently, although they are sometimes removed later in rare cases if irritation or infection occurs.
Some AS patients may eventually need joint replacement therapy—usually in the knees or hips—for severe damage that makes daily activities like walking or climbing stairs difficult. During this procedure, the surgeon removes the damaged joint and replaces it with one made from metal, plastic, or ceramics.
- AS in Women (1): BMJ Open. (2014). "Increasing Proportion of Female Patients With Ankylosing Spondylitis: A Population-based Study of Trends in the Incidence and Prevalence of AS." bmjopen.bmj.com/content/bmjopen/4/12/e006634.full.pdf
- AS in Women (2): Current Rheumatology Reports. (2018). "Gender Differences in Axial Spondyloarthritis: Women Are Not So Lucky." doi.org/10.1007/s11926-018-0744-2
- 2019 Axial Spondyloarthritis Treatment Recommendations: Arthritis & Rheumatology. (2019). "2019 Update of the American College of Rheumatology/ Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis" rheumatology.org/Portals/0/Files/AxialSpA-Guideline-2019.pdf
- The Role of Exercise: Spondylitis Association of America. (2018). "The Role of Exercise in Spondyloarthritis/" spondylitis.org/LinkClick.aspx?fileticket=fo_RrqLaNaQ%3d&portalid=0
- Combining NSAIDs and Biologics to Treat AS: American College of Rheumatology. (2016). “Combination of NSAIDs and TNF-inhibitors shows benefit for ankylosing spondylitis.” sciencedaily.com/releases/2016/11/161113154759.htm
- Exercise Recommendations: Seminars in Arthritis and Rheumatism. (2016). “Exercise for Ankylosing Spondylitis: An Evidence-Based Consensus Statement.” ncbi.nlm.nih.gov/pubmed/26493464
- The Latest as Therapies and Most Recent Discoveries: F1000 Research. (2018). “Recent advances in ankylosing spondylitis: understanding the disease and management.” f1000research.com/articles/7-1512
- Role of Methotrexate: Annals of Rheumatic Diseases. (2015). "The Effect of Comedication With Conventional Synthetic Disease Modifying Antirheumatic Drugs on TNF Inhibitor Drug Survival in Patients With Ankylosing Spondylitis and Undifferentiated Spondyloarthritis: Results From a Nationwide Prospective Study." pubmed.ncbi.nlm.nih.gov/25710471/