Exercise and physiotherapy
Exercise is important to maintain a general level of health and to address the stiffening of the spine that is characteristic of AS. Maintaining a good posture with a straight back will also help to stop the spine becoming bent and fused. Straightforward breathing and stretching exercises are considered to be helpful but more detailed advice should be given by a physiotherapist.
Swimming is considered to be very beneficial as the body is supported by the water and joints and muscles can be exercised without the risk of jarring.
Non-Steroidal anti-inflammatory drugs(NSAIDs)
Research has shown that NSAIDs are effective in improving pain and function in AS. The EULAR guidance on the management of AS says that "NSAIDs are recommended as first line drug treatment for patients with AS with pain and stiffness." Nsaids are not without risk, they are known to increase the risk of gastro-intestinal problems such as stomach ulcers and bleeds. Cox-2 inhibitors(Coxibs) are a type of NSAID but don't have as much risk of stomach problems. Coxibs are thought to carry a heightened risk of heart problems.
For people who have an increased risk of gastro-intestinal problems a grastroprotective agent should be used alongside the NSAID. The National Institute of Clincal Excellence has stated that Coxibs should only be given to people who are not at risk from cardiovascular disease.
Analgesics and Corticosteroid Injections
The Eular guidance states that paracetamol and opiods "might be considered for pain control in patients in whom NSAIDs are insufficient, contraindicated, and/or poorly tolerated." Paracetamol does not present any kind of risk with regard to gastrointestinal problems.
The Eular guidance says that "corticosteroid injections directed to the local site of musculoskeletal inflamation may be considered."
According to the Arthritis Research Campaign (ARC) site, side effects with steroid injections are rare although the injections may cause facial flushing or interfere with the menstrual cycle. Sometimes thinning of the skin occurs around the injection site.
Disease Modifying Anti-Rheumatic Drugs (DMARDS)
The Eular guidance does not recommend the use of DMARDS for ankylosing spondylitis. It does however say that Sulfasalazine may be considered in patients with peripheral arthritis.
Biological Therapies.
Tumour necrosis factor alpha (TNFa) is a substance that is involved in the process of inflammation and three anti-TNF treatments are now available which prevent the inflammatory action.
The Eular recommendations say that "Anti-TNF treatment should be given to patients with persistently high disease activity despite conventional treatments." In the UK three TNF inhibitors are available for people with AS- etanercept, infliximab and adalimumab. Anti-TNF drugs inhibit the action of the tumor necrosis factor protein which causes the inflammation in the joints.
Because anti-TNFs act on the immune system, people are more susceptible to food-borne infections like listeria and salmonella. The ARC site recommends avoiding the following foods:
Common side effects with all anti-TNF agents are;
Etanercept
Etanercept works by preventing TNFa from attaching itself to the tissue in the joint.
Etanercept is given by injection at a twice weekly dose of 25mg and usually takes between two and twelve weeks to take effect.
Taking etanercept can lead to a reduced blood count which makes people more prone to infection. Because people are particularly at risk from tuberculosis, patients are screened for TB prior to starting with etanercept.
The National Institue for Health and Clinical Excellence looked at six high quality random controlled trials involving etanercept and found that it was responsible for improvement in 50-75% of patients.
Infliximab
Infliximab works by attaching itself to TNFa and making it inactive.
Infliximab is given intravenously (via a drip) in hospital. The first infusion is followed by another after two weeks and then another after a further four weeks. Infusions are then given every eight weeks. Infliximab takes between two and twelve weeks to take effect.
In the treatment of rheumatoid arthritis infliximab is given alongside methotrexate but it is felt that there is no need to do this when treating AS.
Adalimumab
Adalimumab works by binding itself to the TNFa proteins making them inactive. Adalmubab is given by injection in 40mg doses once every two weeks. Like other anti-TNF medication, people should be screened for tuberculosis before starting with adalimumab.
Surgery
The Eular recommendations state that total hip replacement should be considered for patients with unmanageable pain or disability. Hip replacement is considered to be effective, the most comprehensive study of 340 cases with 83% of subjects reporting good to excellent pain relief and 52% reporting good to excellent improvement in function.
Spinal surgery is used to correct disabling deformities. A procedure known has closing wedge lumbar osteotomy is particularly effective in restoring balance and horizontal vision.
