If you are living with AS, you may find that over time, your prescribed medications no longer sufficiently control your symptoms. In these cases, your rheumatologist may consider switching you to a different treatment. AS is an autoimmune disease that causes your immune system to attack your spine, causing back and joint pain as well as back stiffness. AS is also called radiographic axial spondyloarthritis, or r-axSpA.
In this article, we explore some of the most common reasons that people with AS switch treatments and how doctors track a particular treatment’s effectiveness.
A person with AS may switch treatments for several reasons: Their current treatment is no longer effective, they’re not seeing the desired outcomes from a medication, or they’re experiencing unpleasant side effects.
In some cases, a person may switch from a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen — which doctors typically recommend first for the treatment of AS — to an advanced treatment, such as a biologic. In other cases, a person may switch from one biologic to another or a different type of medication entirely.
Doctors often prescribe biologic medications to prevent AS from becoming more severe over time. You may need to try more than one biologic drug to find one that works for you. All biologic drugs function differently. Therefore, a lack of success with one biologic doesn’t mean all biologics will be unsuccessful.
Sometimes, a biologic drug will work well for a while and then become less effective over time. This may be because you’ve developed antibodies to that particular biologic. Your body has developed an immune response against the drug, making it less effective. In this case, your doctor may recommend switching to a different biologic of the same class, a different class of biologic, or another type of medication.
Switching or discontinuing biologic drugs is fairly common, although it’s not a universal experience for people with AS or other types of spondyloarthritis. About 20 percent to 30 percent of people with spondyloarthritis who try a biologic stop taking it because the treatment didn’t control the condition. Another 10 percent to 20 percent stop using this treatment because it becomes less effective after initially working or they develop problematic side effects. Research from Norway and Denmark found that between 15 percent and 30 percent of people with AS switched to a different biologic over eight to nine years.
According to a recent survey study of rheumatologists, the most common reasons for discontinuation or switching to different biologic treatment options were:
The main goals when treating AS are to:
If your symptoms do not improve while using a particular medication, talk to your doctor about switching your treatment. Bear in mind that it may take several weeks on a new medication before you’ll notice changes in your symptoms. Make sure to give a treatment enough time to work before discontinuing it and switching to something else.
By reviewing X-rays, MRIs, and other scans, doctors can evaluate how active AS is and determine how well current medications are treating your condition. AS can cause softer tissues in your back to fuse into harder bone, a sign that can be seen on X-rays.
Doctors can use several number-based scales to track a treatment’s effectiveness. These scales are often used in clinical trials and research studies to measure the benefits of new treatments. Scales may measure factors such as back pain, spinal stiffness, and overall well-being. The most popular of these scales is the Assessments in SpondyloArthritis International Society Response Criteria (ASAS 20).
There are several drugs approved by the U.S. Food and Drug Administration (FDA) for AS. These drugs are sometimes called disease-modifying antirheumatic drugs (DMARDs). But before DMARDs are used, the first-line treatment for any inflammatory condition is over-the-counter NSAIDs.
If NSAIDs do not relieve symptoms, the first DMARD a doctor will prescribe is often a tumor necrosis factor-alpha (TNF-alpha) inhibitor. TNF-alpha inhibitors block a chemical in the body that causes inflammation. Types of TNF-alpha inhibitors include:
If TNF inhibitors don’t work, other biologic DMARDs can be used. Some of these target another molecule called interleukin-17 (IL-17). These IL-17 blockers include secukinumab (Cosentyx) and ixekizumab (Taltz).
Other traditional DMARDs like sulfasalazine (Azulfidine) and methotrexate (Otrexup) can also be used, especially if you also have inflammatory bowel disease such as ulcerative colitis, which can be worsened by IL-17 inhibitors.
Your doctor may suggest a Janus kinase (JAK) inhibitor if biologic drugs don’t work for you or if they have stopped working. JAKs are proteins that act as signals from cells to other proteins. JAK inhibitors are small, lab-designed molecules that are designed to “turn off” the JAK signaling that produces inflammatory chemicals. Unlike biologic drugs, which are injected, JAK inhibitors are taken orally.
The JAK inhibitors Tofacitinib (Xeljanz) and upadacitinib (Rinvoq) are currently approved by the FDA to treat AS. Recent studies have found them useful in treating AS symptoms and slowing the progression of the disease.
Changing your AS treatments is a decision that should be made between you and your health care providers. Make sure that you regularly follow up as scheduled with your rheumatologist and any other members of your health care team.
Let your doctor know what problems and complications you may be having and how well you are tolerating your current medications. This will help in a process called shared decision-making, in which you and your health care provider work together to determine your best treatment plan, drawing on your own experiences and preferences and the doctor’s expertise. Shared decision-making is one of the best predictors of good outcomes for people living with AS.
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