Ankylosing Spondylitis

Treatment Overview

Treatment for ankylosing spondylitis focuses on relieving pain and stiffness, reducing inflammation, keeping the condition from getting worse, and enabling you to continue daily activities. Early diagnosis and treatment may reduce pain, stiffness, inflammation, and deformity.

Talk with your doctor about the best treatment approach for your condition. A consultation with a rheumatologist is often recommended, especially to confirm the diagnosis and lay out a treatment plan. Your family doctor or general practitioner can treat mild cases, or you may be referred to a rheumatologist, orthopedic surgeon, or physiatrist.

Initial treatment

Initial treatment for ankylosing spondylitis may include:

• Education, so you know what you can expect as ankylosing spondylitis progresses and how you can minimize problems that can be caused by your condition.
• Conditioning and strengthening exercises, to maintain mobility and control pain. People who exercise regularly find they have less pain and stiffness than those who are less active.³
• Non-steroidal anti-inflammatory drugs (NSAIDs), to relieve pain and stiffness, reduce inflammation, and help with physiotherapy. Some people seem to get more benefit from daily NSAIDs than from taking NSAIDs just when they notice symptoms. Talk to your doctor about using NSAIDs for ankylosing spondylitis, including how much to take and how often to take it.
• Physiotherapy to maintain proper posture, and deep breathing exercises to enhance lung capacity. A physiotherapist can also help you learn to use heat and cold to help control your pain and stiffness. Heat can help with relaxation and pain relief, and cold can help decrease inflammation.
• Assistive devices such as canes or walkers, which allow you to maintain physical activity while reducing stress on joints.
• Alternative therapies such as yoga or acupuncture, which may help relieve pain and improve quality of life.

Have a conversation with your doctor about your job. While people with ankylosing spondylitis feel better if they stay active and exercise regularly, a job that is physically demanding—such as a job that requires lots of heavy lifting—could increase your symptoms.

Ongoing treatment

If initial treatment does not sufficiently reduce the pain and inflammation associated with ankylosing spondylitis, and as your condition progresses, ongoing treatment may include:

• Conditioning and strengthening exercises, to maintain mobility and control pain. People who exercise regularly find they have less pain and stiffness than those who are less active.³ In addition to general conditioning and strengthening, walking and swimming are good activities for people with ankylosing spondylitis. Some people continue to participate in sports as well. Talk to your doctor or physiotherapist about activities that will help you and that you will enjoy.
• Medicine. Doctors usually will first recommend non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation. However, additional, stronger medicines may be needed.
  • Corticosteroids, which are similar to natural hormones produced in the body, help reduce inflammation. Corticosteroids injected into stiff, painful joints may be helpful.¹
  • Disease-modifying antirheumatic drugs (DMARDs) may help relieve pain in joints other than the spine and pelvis. The DMARD most often studied and prescribed for ankylosing spondylitis is sulfasalazine, which is a combination of ASA and an antibiotic. It is given by mouth (orally) and is available in extended-release tablets. It is also often used to treat rheumatoid arthritis. Some people find that another drug called methotrexate relieves pain in joints other than the spine.
  • Drugs known as "biologic agents" or "anti-TNF-alpha" drugs reduce inflammation by blocking a protein called tumour necrotizing factor (TNF) that causes inflammation.
    • Etanercept is a medicine you inject under the skin.
    • Infliximab is an intravenous medicine that is injected directly into a vein.
    • Adalimumab is a medicine you inject under the skin. It is mostly used for rheumatoid arthritis and psoriatic arthritis, but it is beginning to be used for ankylosing spondylitis as well.
    • Other drugs, especially those used to treat rheumatoid arthritis, are being studied as treatments for ankylosing spondylitis. Talk to your doctor if you are interested in clinical trials of new medicines.
• Physiotherapy, to help you maintain good posture, and deep breathing exercises, to enhance your lung capacity. A physiotherapist can also help you learn to use heat and cold to help control your pain and stiffness. Heat can help with relaxation and pain relief, and cold can help decrease inflammation.
• Assistive devices such as canes or walkers, which allow you to maintain physical activity while reducing stress on joints.
• Alternative therapies such as yoga or acupuncture, which may help relieve pain and improve quality of life.

Your doctor will treat complications of ankylosing spondylitis as they occur. For example, iritis may be treated with medicines that can help reduce inflammation of the eye, such as corticosteroids or mydriatic eyedrops.

Treatment if the condition gets worse

In rare cases, you may need surgery to replace joints that are severely damaged by the inflammation of ankylosing spondylitis. The most common surgery done is hip replacement surgery. Spine surgery is done in a very small number of people with ankylosing spondylitis. If there is loosening of the top two vertebrae in the neck and there are signs of pressure on the spinal cord such as numbness or clumsiness in the hands or arms, a surgeon may permanently join (fuse) the two vertebrae together. In very rare cases, spinal surgery may be done to straighten a part of the spine that has become severely curved, but the surgery is risky and cannot restore motion.

Because ankylosing spondylitis is a lifelong condition, other treatment may include complementary and alternative medicine therapies, which can reduce symptoms, help manage pain, and improve quality of life. Complementary and alternative medicine is the term for a wide variety of health care practices that may be used along with or in place of standard medical treatment. These therapies may include yoga and acupuncture.

Even if your symptoms are under control, you should see your doctor (often a rheumatologist) every year to watch for and treat any complications. People with hip symptoms and perhaps those whose disease started in their teens may be at risk for a more severe progression of ankylosing spondylitis.⁴

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Author:	Shannon Erstad, MBA/MPH	Last Updated: August 21, 2007
Medical Review:	E. Gregory Thompson, MD - Internal Medicine Brian D. O'Brien, MD - Internal Medicine Anne C. Poinier, MD - Internal Medicine Stanford M. Shoor, MD - Rheumatology
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