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Advanced Treatment Options for Ankylosing Spondylitis

Posted on August 19, 2021
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Jessica Wolpert

  • If nonsteroidal anti-inflammatory drugs (NSAIDs) aren’t working to control your ankylosing spondylitis (AS), more advanced treatments are an option.
  • Janus kinase inhibitors and biologics can help treat symptoms and slow the progression of ankylosing spondylitis.
  • In rare cases of advanced ankylosing spondylitis, surgery may be appropriate.

Ankylosing spondylitis is a disorder in which the immune system mistakenly attacks healthy tissue in the spine, causing inflammation, pain, and joint damage. As the disease progresses, joints can become so damaged that they cause ankylosis — formation of new bone. This fuses the joints together and limits movement. Ankylosing spondylitis is also referred to as radiographic axial spondyloarthritis or radiographic axSpA.

Treatment goals for ankylosing spondylitis include relieving symptoms, maintaining or improving physical function, minimizing the complications of AS, and slowing the progression of the disease. The right treatment for you will depend on your symptoms and other signs of your condition. Throughout your journey with AS, you may need to switch from the initial medications your doctor prescribed to advanced treatments.

First-Line Treatments

Nonsteroidal anti-inflammatory drugs are the first line of treatment for ankylosing spondylitis symptoms like back pain. NSAIDs include common over-the-counter medications, such as ibuprofen (Advil) and naproxen (Aleve), as well as prescription drugs like indomethacin (Indocin) and diclofenac (Voltaren). NSAIDs treat pain and reduce inflammation.

People with AS are sometimes prescribed corticosteroids to relieve inflammation, but long-term use of corticosteroids is not recommended. Older disease-modifying antirheumatic drugs (DMARDs) like methotrexate and sulfasalazine are sometimes prescribed to treat AS, although these drugs are generally not a preferred option.

NSAIDs aren’t always enough to manage symptoms and keep ankylosing spondylitis from progressing. If that’s the case, your doctor may recommend more advanced treatments. Advanced treatments for ankylosing spondylitis usually include newer classes of drugs, such as biologics or JAK inhibitors. Talk to your doctor if your current treatment plan is not sufficiently controlling your pain and other symptoms. Your doctor can help you understand if it’s time to switch ankylosing spondylitis treatments.

Biologics

Biologic drugs work to reduce inflammation and slow the progression of ankylosing spondylitis. Biologic drugs for AS and other forms of inflammatory arthritis may also be referred to as biologic DMARDs. They use bioengineered molecules to target specific aspects of the immune system that cause inflammation.

The most common biologic treatment for ankylosing spondylitis is the tumor necrosis factor (TNF) alpha inhibitor. TNF-alpha inhibitors block a chemical in the body called tumor necrosis factor, which causes inflammation. Taking a TNF-alpha inhibitor reduces the inflammation caused by ankylosing spondylitis and halts disease activity, slowing the progress of joint damage and other symptoms of AS.

TNF-alpha inhibitors include etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade)​​​​​​​, golimumab (Simponi)​​​​​​​, and certolizumab pegol (Cimzia)​​​​​​​. These drugs are administered either through self-injection or through injections given in a health care provider’s office. The injections are usually taken every few weeks. Side effects of TNF-alpha inhibitors include an increased risk of infection, skin reactions near the site of the injection, and rare neurological complications.

TNF-alpha inhibitors might increase the risk of some cancers, such as lymphoma and nonmelanoma skin cancer. If you are taking a TNF-alpha inhibitor, an annual skin examination is important.

Because of the increased risk of infection, people who want to take TNF-alpha inhibitors should be tested for tuberculosis before starting the medication. In addition, people with multiple sclerosis or significant heart failure should not use TNF inhibitors.

Like TNF-alpha inhibitors, interleukin (IL) inhibitors treat ankylosing spondylitis by blocking a chemical that causes inflammation. IL-17 inhibitors include secukinumab (Cosentyx) ​​​​​​​and ixekizumab (Taltz). IL-17 inhibitors have similar side effects as TNF inhibitors, and they also can cause or exacerbate inflammatory bowel disease. Interleukin inhibitors are taken as injections.

JAK Inhibitors

A Janus kinase (JAK) inhibitor may be an option if biologic drugs don’t work for you, or have stopped working. JAK inhibitors are currently approved by the U.S. Food and Drug Administration (FDA) to treat rheumatoid arthritis and certain other conditions. Recent studies found them useful in treating ankylosing spondylitis symptoms and slowing the progression of the disease. Unlike biologic drugs that are injected, JAK inhibitors are taken orally.

Janus kinases are proteins that act as signals from cells to other proteins. There are three types of Janus kinases: JAK1, JAK2, and JAK3. Janus kinases respond to cytokines, small proteins involved in cell signaling. When cytokines attach to a cell, JAK proteins “turn on” and tell cells to make more cytokines, producing inflammation. Normally, this inflammation is actually healthy — it’s used to kill harmful viruses and bacteria. However, if you have ankylosing spondylitis, JAK signaling doesn’t shut off when it should.

JAK inhibitors are small, lab-designed molecules designed to “turn off” the JAK signaling that produces inflammatory chemicals. Because they target very specific proteins, JAK inhibitors may be easier to tolerate than TNF-alpha inhibitors.

Tofacitinib (Xeljanz) ​​​​​​​and upadacitinib (Rinvoq) are JAK inhibitors that have been studied as treatments for ankylosing spondylitis. In a 2020 study of 269 people with ankylosing spondylitis, 41 percent of people taking tofacitinib for 16 weeks showed significantly improved inflammation and pain levels, compared to only 13 percent of people taking a placebo. A clinical trial of 187 people taking upadacitinib showed that 52 percent of people with ankylosing spondylitis had improvements in inflammation and pain.

Xeljanz targets all three JAK proteins, while Rinvoq inhibits the JAK1 protein.

Like TNF-alpha inhibitors, JAK inhibitors can raise your risk of infection and your risk for certain cancers. In addition, JAK inhibitors also can be a risk factor for blood clots.

Surgery

When other treatments do not relieve severe ankylosing spondylitis symptoms, spinal surgery may be appropriate. Advanced symptoms of AS that may require surgery include kyphosis (curvature of the spine), neuropathy, spinal instability, and severe hip involvement.

Spinal surgeries to treat AS include osteotomy, decompression, and spinal fusion. The type of surgery used depends on what specific problems are causing symptoms.

Read more about surgery for ankylosing spondylitis.

Connect With Others

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Are you living with ankylosing spondylitis? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Overview of Ankylosing Spondylitis — Spondylitis Association of America
  2. Axial Spondyloarthritis — Arthritis Foundation
  3. 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 — Arthritis & Rheumatology
  4. Tumor Necrosis Factor (TNF) Inhibitors — American College of Rheumatology
  5. Medications Used to Treat Ankylosing Spondylitis and Related Diseases — Spondylitis Association of America
  6. Ankylosing Spondylitis and the Risk of Cancer — Oncology Letters
  7. Tumor Necrosis Factor Inhibitors — StatPearls
  8. Tofacitinib for the Treatment of Ankylosing Spondylitis: A Phase III, Randomised, Double-Blind, Placebo-Controlled Study — BMJ Journals: Annals of the Rheumatic Diseases
  9. Efficacy and Safety of Upadacitinib in a Randomized, Double-Blind, Placebo-Controlled, Multicenter Phase 2/3 Clinical Study of Patients With Active Ankylosing Spondylitis — American College of Rheumatology
  10. The Role of the JAK/STAT Signal Pathway in Rheumatoid Arthritis — Therapeutic Advances in Musculoskeletal Disease
  11. The Arrival of JAK Inhibitors: Advancing the Treatment of Immune and Hematologic Disorders — BioDrugs
  12. Upadacitinib and Filgotinib: The Role of JAK1 Selective Inhibition in the Treatment of Rheumatoid Arthritis — Drugs in Context
  13. Tofacitinib (Oral Route) — Mayo Clinic
  14. Ankylosing Spondylitis — Weill Cornell Brain and Spine Center
All updates must be accompanied by text or a picture.
Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Jessica Wolpert works to empower patients through the creation of content that illuminates treatments' effects on the everyday lives of people with chronic conditions. Learn more about her here.

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