How Do Biologics Work to Treat Ankylosing Spondylitis and nr-axSpA? | MySpondylitisTeam

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How Do Biologics Work to Treat Ankylosing Spondylitis and nr-axSpA?

Updated on October 12, 2023

  • There are different classes of drugs to help manage symptoms of spondyloarthritis. Biologics are a category of medications that treat axial spondyloarthritis (axSpA) by targeting specific proteins involved in inflammation.
  • There are several classes of biologics for axSpA that work in different ways.
  • Biologics may work quickly to improve axSpA symptoms and can slow the progression of irreversible joint damage.
  • Some biologics are approved by the U.S. Food and Drug Administration (FDA) and/or the European Medicines Agency (EMA) to treat ankylosing spondylitis only while others are approved to treat both ankylosing spondylitis and nonradiographic axial spondyloarthritis, when joint damage is not yet visible in X-rays.

Many classes of drugs have been developed to help manage symptoms and flares of spondyloarthritis. Biologic drugs are believed to slow joint damage by reducing inflammation in axSpA.

Biologics are drugs made of proteins, sugars, or nucleic acids.1 Unlike other drugs that are chemically synthesized, biologics are derived from living organisms. Examples of biologics include vaccines, gene therapy, and monoclonal antibodies used to treat cancer and arthritis. Biologics that are disease-modifying antirheumatic drugs (DMARDs) can be used to treat rheumatic diseases such as axSpA.

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Types of Spondyloarthritis

It’s helpful to review the terminology around types of spondyloarthritis before getting into the specifics of how they are treated with biologics. “Spondyloarthritis” refers to a category of inflammatory diseases that primarily affect the spine and other joints.2 Types of spondyloarthritis include psoriatic arthritis, arthritis associated with inflammatory bowel disease, and axial spondyloarthritis.3

Axial spondyloarthritis specifically affects the spine.4

There are two subtypes under the umbrella of axSpA: nonradiographic axSpA (nr-axSpA) and radiographic axSpA or ankylosing spondylitis (AS).5 Damage to the sacroiliac (SI) joints — the joints that connect the hips to the spine — in nr-axSpA cannot be seen in X-rays, while changes in AS are apparent in X-rays. Every case of axSpA begins as nonradiographic. Between 10% and 40% of nr-axSpA cases progress to become radiographic within 10 years.6

Your treatment options differ depending on which subtype of axSpA you have. While some biologic DMARDs have been approved by the FDA and/or EMA to treat AS only, others are approved to treat both AS and nr-axSpA.

Read more about types and symptoms of spondyloarthritis.

How Do Biologics Work?

To understand how biologic DMARDs are used to treat axSpA, it is important to know a little more about the immune system, inflammation, and a class of biologics known as monoclonal antibodies.

What Are Monoclonal Antibodies?

Antibodies are proteins that form a vital part of the immune system. They are produced by specialized immune cells, known as B-cells, to fight bacterial or viral infections.7 The human body is capable of making almost 100 billion types of B-cells, and each type of B-cell produces only one type of antibody.8 Each antibody is a protein that recognizes and interacts with a very specific target.

B-cells can also be genetically altered in a lab to produce specific antibodies that will attach to a target protein. These are known as monoclonal antibodies because they are produced from one type of B-cell.9

Every antibody made by that B-cell will have the same properties. Researchers have designed monoclonal antibodies to target specific proteins on the outside of immune cells, cancer cells, and other abnormal cells associated with disease.

Biologics for Axial Spondyloarthritis

There are several categories of biologics with different targets. Currently, tumor necrosis factor-alpha (TNF-ɑ) inhibitors and interleukin-17A (IL-17A) blockers are the only categories of biologic DMARDs approved to treat axSpA in the U.S. An IL-17A and interleukin-17F (IL-17F) inhibitor is also approved to treat nr-axSpA and AS in the European Union. Doctors may recommend biologics in cases where nonsteroidal anti-inflammatory drugs (NSAIDs) did not work.10

How Effective Are Biologics for AxSpA?

Traditionally, NSAIDs such as ibuprofen (Advil), naproxen (Aleve), and celecoxib (Celebrex) are used to treat symptoms of axSpA, temporarily managing pain and inflammation.11 However, new biologic DMARDs work by targeting the cause of inflammation at its source, slowing disease progression and irreversible SI joint and spinal damage.

While axSpA cannot be cured, treatment can often stop or reduce inflammation to the lowest levels possible to relieve symptoms and slow further joint damage. If axSpA continues to progress, it can lead to permanent SI joint and spinal damage and disability. When NSAIDs don’t work, biologic DMARDs may be used to help control axSpA inflammation and reduce symptoms.

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Are biologics working for you?

What to Expect When Starting Biologics

All biologics are injected, usually given as either subcutaneous (under the skin) injections or intravenous (IV) infusions.12 Biologics cannot be taken by mouth because they would be broken down in the stomach and intestines before being absorbed into the bloodstream.

Before you start biologic therapy, you may undergo some screening tests to make sure you are not at risk from any underlying conditions. Screening often includes tests for tuberculosis and hepatitis B and C.13 You may be monitored regularly for these or other conditions during treatment with biologics to make sure you are not at risk of developing any complications.

Administering Biologics

The route of administration for your specific drug will determine whether you need to go to a medical office to receive your treatment or if it can be done at home.14

Subcutaneous Injections

Certain biologic medications can be delivered through an injection that goes under the skin. For some drugs, using an auto-injector or a needle and syringe, you can give yourself a subcutaneous injection at home or have a family member or caregiver help you.14

Your rheumatologist might ask you to self-administer your first dose at their office to ease your worries and help build confidence. For other drugs, you may have to receive your injections at the doctor’s office.14 If you will self-administer, be sure to follow all instructions given by your doctor and pharmacist to ensure that the injection is sterile and effective.

Some people use ice to numb the injection-site before self-injecting.14 Another tip to reduce injection site pain: Alternate your body’s injection sites to minimize scarring, bruising, and sensitivity over time. The arms, thighs, and stomach are all common locations for injection.14

If you are storing your medications at home, pay close attention to the storage instructions given to you. Most biologics must be refrigerated and slowly brought to room temperature before being used. Heating the medication too quickly or putting it back in the fridge after it has thawed can make the drug less effective. Using an ineffective drug may give you an inadequate response to treatment, so make sure to store your drugs properly.14 After use, safely dispose of all needles.

Intravenous Infusions

Some biologics can be given only through a drip that goes into your vein. This must be done by a health care professional at the doctor’s office or another medical facility.14 Unlike an injection, an IV infusion can take a few hours, but the process is usually done less frequently than injections.

Biologics are all administered at a different frequency — weeks or months apart — depending on the medication.15 Carefully follow your doctor’s instructions about when to self-administer your doses or return to their office. If you have any questions about the administration of your biologics, be sure to ask your rheumatology provider.

Side Effects of Biologics

In most cases, the benefits of using approved drugs to treat a condition outweigh the possible side effects you may experience. If you notice side effects or worsening of your symptoms, talk to your doctor about how to manage these issues and ask whether they may fade over time.

Common side effects associated with biologic drugs include:14

  • Redness, pain, swelling, and itching at the injection-site
  • Increased risk of infections, because the drugs work by suppressing the immune system
  • Headaches
  • Nausea
  • Infusion reactions, which are similar to allergic reactions (pain, swelling, flushing, headache, etc.)

    Always listen to your body. If you experience any of these new symptoms after using biologic drugs, contact your doctor right away:14,15

    • Fever, sweat, or chills
    • Shortness of breath
    • Cough
    • Chest pain
    • Dizziness
    • Vision problems
    • Painful rash or sores
    • Diarrhea or stomach pain
    • Bleeding or bruising easily

    These are all signs of an infection or a more serious condition that should be addressed immediately.

    Finding Support for Spondyloarthritis

    You are not alone in living with spondyloarthritis. When you join MySpondylitisTeam, you gain a community of more than 90,000 people who know what it’s like to live with inflammatory arthritis. More than 3,300 members report treating their axSpA with biologics.

    GL-DA-2300220. Date of preparation: September 2023
    © UCB Biopharma SRL, 2023. All rights reserved.

    1. What are ‘biologics’ questions and answers. U.S. Food and Drug Administration. Center for Biologics Evaluation and Research. Updated February 6, 2018. Accessed September 2023.
    2. Rath L. The spondyloarthritis family. Arthritis Foundation. April 11, 2022. Accessed September 2023.
    3. Mcgonagle DG, Mcinnes IB, Kirkham BW, Sherlock J, Moots R. The role of IL-17A in axial spondyloarthritis and psoriatic arthritis: recent advances and controversies. Ann Rheum Dis. 2019;78(9):1167-78. doi:10.1136/annrheumdis-2019-215356
    4. Poddubnyy D. Axial spondyloarthritis: is there a treatment of choice? Ther Adv Musculoskelet Dis. 2013;5(1):45-54. doi:10.1177/1759720X12468658
    5. Lubrano E, Perrotta FM, Manara M, et al. Improvement of function and its determinants in a group of axial spondyloarthritis patients treated with TNF inhibitors: a real-life study. Rheumatol Ther. 2020;7(2):301-10. doi:10.1007/s40744-020-00197-5
    6. Protopopov M, Poddubnyy D. Radiographic progression in non-radiographic axial spondyloarthritis. Expert Rev Clin Immunol. 2018;14(6):525-33. doi:10.1080/1744666X.2018.1477591
    7. Antibody. National Human Genome Research Institute. Updated January 9, 2023. Accessed September 2023.
    8. Glanville J, Zhai W, Berka J, et al. Precise determination of the diversity of a combinatorial antibody library gives insight into the human immunoglobulin repertoire. Proc Natl Acad Sci U S A. 2009;106(48):20216-21. doi:10.1073/pnas.0909775106
    9. Shepard HM, Phillips GL, Thanos CD, Feldmann M. Developments in therapy with monoclonal antibodies and related proteins. Clin Med (Lond). 2017;17(3): 220-32. doi:10.7861/clinmedicine.17-3-220
    10. Bruner V, Atteno M, Spanò A, Scarpa R, Peluso R. Biological therapies for spondyloarthritis. Ther Adv Musculoskelet Die. 2014;6(3):92-101. doi:10.1177/1759720X14535512
    11. Kroon FPB, van der Burg LRA, Ramiro S, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for axial spondyloarthritis (ankylosing spondylitis and non-radiographic axial spondyloarthritis). Cochrane Database Syst Rev. 2015;(7):CD010952. doi:10.1002/14651858.cd010952.pub2
    12. Anselmo AC, Gokarn Y, Mitragotri S. Non-invasive delivery strategies for biologics. Nat Rev Drug Discov. 2018;18(1):19-40. doi:10.1038/nrd.2018.183
    13. Schmajuk G. Few patients starting biologics, DMARDs screened for HBV, HCV. Healio. November 13, 2019. Accessed September 2023.
    14. How to give yourself biologic injections: tips from patients and doctors. CreakyJoints. April 25, 2019. Accessed September 2023.
    15. de Falla K. Biologics: basic facts for patients. Arthritis-health. November 29, 2017. Accessed September 2023.
          Updated on October 12, 2023
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          Emily Wagner, M.S. holds a Master of Science in biomedical sciences with a focus in pharmacology. She is passionate about immunology, cancer biology, and molecular biology. Learn more about her here.
          Scarlett Bergam, M.P.H. is a medical student at George Washington University and a former Fulbright research scholar in Durban, South Africa. Learn more about her here.
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