If you are living with ankylosing spondylitis, over time you may find that your prescribed medications no longer sufficiently control your symptoms. In this case, your rheumatologist may consider switching you to a different treatment.
Ankylosing spondylitis 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. In this article, we will explore some of the most common reasons people with AS switch treatments and how doctors track a particular treatment’s effectiveness.
A person with ankylosing spondylitis 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 — which is considered a first-line treatment — to an advanced treatment, such as a biologic. In other cases, a person may switch from one biologic to another or to 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. Individual 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, then become less effective over time. This may be because you’ve developed antibodies to that particular biologic. This means 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 a completely different medication.
Switching or discontinuing biologic drugs is fairly common, though 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 stop using a biologic because of an inadequate response to the treatment. About 10 percent to 20 percent of people with spondyloarthritis stop using a biologic because it loses efficacy 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 within eight or nine years.
According to a recent survey study of rheumatologists, the most common reasons for switching to different biologic treatment options were:
If your symptoms do not improve over the course of your current treatment, 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. It’s important to give a treatment enough time to work before discontinuing it and switching to something else.
By reviewing X-rays, MRI, and other scans, doctors can assess disease activity and determine how well current medications are treating your AS. AS can cause structural damage to the spine and sacroiliac joints, 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 on new treatments to measure their benefits. Scales may measure factors such as pain, spinal stiffness, and overall well-being. One of the most popular of these scales is the Assessment of SpondyloArthritis International Society (ASAS) response criteria.
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 are not effectively managing your AS, 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 Cosentyx (secukinumab). Other drugs like Azulfidine (sulfasalazine) can be used, especially if you also have an inflammatory bowel disease such as ulcerative colitis.
Your doctor may suggest a Janus kinase (JAK) inhibitor if biologic drugs don’t work for you or 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.
JAK inhibitors are currently approved by the FDA to treat rheumatoid arthritis and certain other conditions. Recent studies have found them useful in treating ankylosing spondylitis symptoms and slowing the progression of the disease.
Changing your AS treatments is a decision that should be made in collaboration with your health care providers. Make sure you regularly follow up as scheduled with your rheumatologist and any other members of your health care team.
Let your doctor know about any complications you have 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 has been shown to be one of the best predictors of good outcomes for people living with AS.
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