Is It Time to Rethink Your AS Treatment?
Finding a medication that works for you is a top priority when you’re diagnosed with ankylosing spondylitis (AS), a chronic inflammatory form of arthritis. “We have very good treatments for AS,” says Terence Starz, M.D., clinical professor of medicine and occupational therapy in the division of rheumatology and clinical immunology at University of Pittsburgh School of Medicine in Pittsburgh, PA. “One of the challenges is to determine the best treatment for the individual.” Keep reading to learn the signs that your treatment plan may need to change.
An Overview of Treatment Options
First, let’s review the basic options for AS treatment. You’ve got your nonsteroidal anti-inflammatory drugs (NSAIDS) like ibuprofen (Advil) and naproxen (Aleve), and then more heavy-duty options like biologic drugs, says Dr. Starz. In addition to medications, your rheumatologist will likely also recommend you stay active with exercise and perhaps even try physical or occupational therapy as additional ways to help keep your symptoms under control, per the Arthritis Foundation. Depending on your specific symptoms and disease, your rheumatologist will help come up with a treatment plan for you, says Dr. Starz. Next up: Signs something needs to shift.
#1: Symptoms Return
One of the clearest signs that you may want to talk with your doctor about whether something needs to change in your treatment for AS is if symptoms you had before starting treatment start to creep back in, says Joerg Ermann, M.D., rheumatologist with the Division of Rheumatology, Inflammation and Immunity at Brigham and Women’s Hospital in Boston, MA. “That’s one of the typical things that can happen. These symptoms often include back pain, stiffness—in particular in the morning—and fatigue,” he explains. “Patients may also have involvement of peripheral joints, so there may be a swollen or painful joint.”
#2: You Have a Flare
Typically, an effective AS treatment will keep your symptoms under control. But if your symptoms flare up while on a particular medication, that could be a sign that you need to reevaluate, says Dr. Ermann. That said, some fluctuation may be expected. “Sometimes that happens when patients are on a monthly schedule, for example, when they inject a drug and then toward the end of that month just before that injection, symptoms get worse and then improve after next injection. That’s a pattern that occasionally happens,” he says.
#3: Symptoms Go Beyond Musculoskeletal
While most people think of back pain when they think of AS, it’s important to watch out for other symptoms that may be AS-related and a sign that your treatment may not be working well enough. “In AS, there can also be disease manifestations outside the musculoskeletal system,” explains Dr. Ermann. “That could be inflammation of the eye (known as uveitis), which is common in up to 40% of patients, skin inflammation, inflammation in the intestine, and others. These are things that can also flare up from AS and may [signal a] need for change in treatment.”
#4: Your Symptoms Worsen
If you’re noticing that your usual symptoms are starting to get worse, rather than staying stagnant or (ideally!) getting better, you may want to have a conversation with your doctor about changing your medication, Dr. Ermann says. “If symptoms are worse for a day or two, that may just be weather-related or physical activity-related, but if the condition changes on a more permanent level for several days in a row, contact the rheumatologist,” says Dr. Ermann. This is also wise if you have a sudden but dramatic change in symptoms, he says—in some cases, that could actually indicate a fracture and not just a flare-up.
How Your Treatment May Shift
Once you’ve identified that you may need a change, you’ll likely be asking—what kind of change? What are my options? Well, that depends on your individual disease, Dr. Ermann says, and your rheumatologist will help you understand your options and weigh the risks and benefits of each. But there are some common scenarios that you may expect. Keep reading to learn about some of these possibilities.
NSAID to NSAID
If you’ve had past success with an NSAID but it’s stopped working adequately, it may be sufficient to simply try a different NSAID in some cases, Dr. Ermann says. Yes, these are often over-the-counter drugs, but don’t discount them—they can be super effective. “When we are targeting AS treatment, we are looking for treatments that can help alleviate inflammation, and NSAIDs are certainly the foundation of treating AS pharmacologically,” says Dr. Starz. “They are very effective—the efficacy is such that the criteria for starting biologics actually include that the patient has already tried NSAIDs and not had significant symptom control.”
NSAID to Biologic
If your NSAID regimen isn’t working adequately for your AS, your doctor may suggest starting you on a biologic, Dr. Ermann says. Biologics are drugs that help target the root causes of inflammation in your body, per the Mayo Clinic. One type of biologic often used for AS is called a tumor necrosis factor (TNF) blocker, and there are currently five of these approved for AS treatment by the U.S. Food and Drug Administration, the Mayo Clinic says. Another class of biologics you may be prescribed is called interleukin-17 (IL-17) inhibitors.
Biologic to Biologic
If you’re on a biologic when you start to notice one of these signs that your treatment may need to shift, your rheumatologist may suggest trying a different biologic, Dr. Ermann says. Again, there are several options available that can be highly effective in treating AS inflammation. “We now have different types of biologics for treatment, and it really depends on the specific circumstances whether one would change to an alternate medication within the same class (for example, one TNF inhibitor to another) or whether it’s more appropriate to switch from one class (mechanism of action) to another,” he explains.
Everyone’s AS Is Different
The good news is there are plenty of effective treatment options available nowadays for AS. While it can be frustrating to find your symptoms are changing and not for the better, know that there’s hope. If you feel like a drug isn’t working, your doctor may suggest you stick it out for a trial period. “Usually we suggest a three-month trial period to see if symptoms improve,” he says. “But careful communication with your health care provider is essential.” Work closely with your rheumatologist to come up with a treatment plan that works best for you.
AS Treatment Information: The Arthritis Foundation. (2021.) “Axial Spondyloarthritis.” arthritis.org/diseases/ankylosing-spondylitis
AS Medications: The Mayo Clinic. (2019.) “Anklyosing Spondylitis.” mayoclinic.org/diseases-conditions/ankylosing-spondylitis/diagnosis-treatment/drc-20354813