Things to know about ankylosing spondylitis
Picture of areas of inflammation in ankylosing spondylitis
- Ankylosing spondylitis is a form of arthritis featuring chronic inflammation of the spine and the sacroiliac joints (sacroiliitis).
- Ankylosing spondylitis belongs to a group of arthritis conditions that tend to cause chronic inflammation of the spine (spondyloarthropathies).
- Ankylosing spondylitis affects males two to three times more commonly than females.
- Ankylosing spondylitis is a cause of back pain in adolescents and young adults.
- The tendency to develop ankylosing spondylitis is genetically inherited.
- The HLA-B27 gene can be detected in the blood of most patients with ankylosing spondylitis.
- Ankylosing spondylitis can also affect the eyes, heart, lungs, and occasionally the kidneys.
- The optimal treatment of ankylosing spondylitis involves medications that reduce inflammation or suppress immunity, physical therapy, and exercise.
Ankylosing Spondylitis Symptom
Lower back pain
Common causes of lower back pain include strain injury from athletics or overuse, disc herniation, kidney infection, pinched nerve in the spine, and pregnancy. Less common causes of back pain include infection of the spine, ankylosing spondylitis with lumbosacral and sacroiliac joint disease, compression fracture of a spinal vertebra, disc ligament tear (annular tear), and spinal tumor or cancer in the bone of the spine.
Symptoms that can be associated with low back pain include
- dull ache,
- sharp pain,
- pulsating pain,
- pain with movement of the spine,
- pins and needles sensation,
- muscle spasm,
- sciatica with shooting pain down one or both lower extremities,
- rash, and
- loss of continence of bowel or bladder.
Read more about causes of low back pain »
What is ankylosing spondylitis?
Ankylosing spondylitis is a form of chronic inflammation of the spine and the sacroiliac joints. The sacroiliac joints are located at the base of the low back where the sacrum (the bone directly above the tailbone) meets the iliac bones (bones on either side of the upper buttocks) of the pelvis. Chronic inflammation in these areas causes pain and stiffness in and around the spine, including the neck, middle back, lower back, and buttocks. Over time, chronic inflammation of the spine (spondylitis) can lead to a complete cementing together (fusion) of the vertebrae, a process referred to as ankylosis. Ankylosis causes loss of mobility of the spine.
Ankylosing spondylitis is also a systemic disease, meaning it can affect tissues throughout the body, not just the spine. Accordingly, it can cause inflammation in and injury to other joints away from the spine manifest as arthritis, as well as to other organs, such as the eyes, heart, lungs, and kidneys. Ankylosing spondylitis shares many features with several other arthritis conditions, such as psoriatic arthritis, reactive arthritis (formerly called Reiter's disease), and arthritis associated with Crohn's disease and ulcerative colitis. Each of these arthritic conditions can cause disease and inflammation in the spine, other joints, eyes, skin, mouth, and various organs. In view of their similarities and tendency to cause inflammation of the spine, these medical conditions are collectively referred to as "spondyloarthropathies." Ankylosing spondylitis is considered one of the many rheumatic diseases because it can cause symptoms involving muscles and joints.
Ankylosing spondylitis is two to three times more common in men than in women. In women, joints away from the spine are more frequently affected than in men. Ankylosing spondylitis affects all age groups, including children. When it affects children, it is referred to as juvenile ankylosing spondylitis. The most common age of onset of symptoms is in the second and third decades of life. Ankylosing spondylitis is often abbreviated AS and has been referred to as Bechterew's disease.
What causes ankylosing spondylitis?
The tendency to develop ankylosing spondylitis is believed to be genetically inherited, and a majority (nearly 90%) of people with ankylosing spondylitis are born with a gene known as the HLA-B27 gene. Blood tests have been developed to detect the HLA-B27 gene marker and have furthered our understanding of the relationship between HLA-B27 and ankylosing spondylitis. The HLA-B27 gene appears only to increase the tendency of developing ankylosing spondylitis, while some additional factor(s), perhaps environmental factors, are necessary for the disease to appear or become expressed. For example, while 7% of the United States population has the HLA-B27 gene, only 1% of the population actually has the disease ankylosing spondylitis. In northern Scandinavia (Lapland), 1.8% of the population has ankylosing spondylitis while 24% of the general population has the HLA-B27 gene. Even among individuals whose HLA-B27 blood test is positive, the risk of developing ankylosing spondylitis appears to be further related to heredity. In HLA-B27-positive individuals who have relatives with the disease, the risk of developing ankylosing spondylitis is 12% (six times greater than for those whose relatives do not have ankylosing spondylitis). This means that not everyone who has the gene will develop ankylosing spondylitis.
Other genes have been identified that are associated with ankylosing spondylitis, including ARTS1 and IL23R. These genes seem to play a role in influencing immune function. It is anticipated that by understanding the effects of each of these known gene risk factors medical researchers will make significant progress in discovering a cure for ankylosing spondylitis.
How inflammation occurs and persists in different organs and joints in ankylosing spondylitis is a subject of active health research. Each individual tends to have their own unique pattern of presentation and activity of the illness. The initial inflammation may be a result of an activation of the body's immune system, perhaps by a preceding bacterial infection or a combination of infectious microbes. Once activated, the body's immune system becomes unable to turn itself off, even though the initial bacterial infection may have long subsided. Chronic tissue inflammation resulting from the continued activation of the body's own immune system in the absence of active infection is the hallmark of an inflammatory autoimmune disease.
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What are home remedies for ankylosing spondylitis?
Physical therapy for ankylosing spondylitis includes instructions and exercises to maintain proper posture. This includes deep breathing for lung expansion and stretching exercises to improve spine and joint mobility. Since ankylosis of the spine tends to cause forward curvature (kyphosis), patients are instructed to maintain erect posture as much as possible and to perform back-extension exercises. Patients are also advised to sleep on a firm mattress and avoid the use of a pillow in order to prevent spine curvature. Ankylosing spondylitis can involve the areas where the ribs attach to the upper spine as well as the vertebral joints, thus limiting breathing capacity. Patients are instructed to maximally expand their chest frequently throughout each day to minimize this limitation.
Physical therapists customize exercise programs for each individual. Swimming often can be a very beneficial form of exercise, as it avoids jarring impact of the spine. Ankylosing spondylitis need not limit an individual's involvement in athletics. People can participate in carefully chosen aerobic sports when their disease is inactive. Aerobic exercise is generally encouraged as it promotes full expansion of the breathing muscles and opens the airways of the lungs.
Cigarette smoking is strongly discouraged in people with ankylosing spondylitis, as it can accelerate lung scarring and seriously aggravate breathing difficulties. Occasionally, those with severe lung disease related to ankylosing spondylitis may require oxygen supplementation and medications to improve breathing.
People with ankylosing spondylitis may need to modify their activities of daily living and adjust features of the workplace. For example, workers can adjust chairs and desks for proper postures. Drivers can use wide rearview mirrors and prism glasses to compensate for the limited motion in the spine.
What are ankylosing spondylitis treatment options?
The treatment of ankylosing spondylitis typically involves the use of medications to reduce inflammation and/or suppress immunity to stop progression of the disease, physical therapy, and exercise. Medications decrease inflammation in the spine and other joints and organs. Physical therapy and exercise help improve posture, spine mobility, and lung capacity.
Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to decrease pain and stiffness of the spine and other joints. Commonly used NSAIDs include indomethacin (Indocin), tolmetin (Tolectin), sulindac (Clinoril), naproxen (Naprosyn), and diclofenac (Voltaren). Their common side effects include stomach upset, nausea, abdominal pain, diarrhea, and even bleeding ulcers. These medicines are frequently taken with food in order to minimize side effects.
In some people with ankylosing spondylitis, inflammation of joints excluding the spine (such as the hips, knees, or ankles) becomes the major problem. Inflammation in these joints may not respond to NSAIDs alone. For these individuals, the addition of disease-modifying antirheumatic drugs (DMARDs) that suppress the body's immune system is considered. These medications, such as sulfasalazine (Azulfidine), may bring about long-term reduction of inflammation. An alternative to sulfasalazine that is somewhat more effective is methotrexate (Rheumatrex, Trexall), which can be administered orally or by injection. Frequent blood tests are performed during methotrexate treatment because of its potential for toxicity to the liver, which can even lead to cirrhosis, and toxicity to bone marrow, which can lead to severe anemia.
Medical research has shown that for persistent ankylosing spondylitis with spinal involvement that is unresponsive to anti-inflammatory medications, both sulfasalazine and methotrexate are ineffective. Newer, effective medications for spine disease attack a messenger protein of inflammation called tumor necrosis factor (TNF). These TNF-blocking medications have been shown to be extremely effective for treating ankylosing spondylitis by stopping disease activity, decreasing inflammation, and improving spinal mobility. Examples of these TNF-blockers include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), and golimumab (Simponi). In 2016, adalimumab (Humira) was approved for the treatment of uveitis (inflammation in the eyes).
Several major points about the treatment of ankylosing spondylitis deserve emphasis. There is an early, underdiagnosed stage of spondylitis that occurs before plain X-ray testing can detect classic changes. Patients who are treated earlier respond better to treatments. Current disease-modifying drugs such as methotrexate, sulfasalazine, and leflunomide (Arava), which can be effective for joint inflammation of joints away from the spine, are not effective for spinal inflammation. If nonsteroidal anti-inflammatory drugs (NSAIDs) are not effective in a patient whose condition is dominated by spinal inflammation (and 50% do respond), then biologic medications that inhibit tumor necrosis factor (TNF inhibitors) or that inhibit interleukin 17 are used.
All TNF inhibitors, including Remicade, Enbrel, Humira, Cimzia, and Simponi can be effective in treating ankylosing spondylitis. The improvement that results for TNF inhibition is sustained during years of treatment. If the TNF inhibitors are discontinued, for whatever reason, relapse of disease occurs in virtually all patients within a year. If TNF inhibitor is then resumed, it is typically effective. Secukinumab (Cosentyx) and ixekizumab (Taltz) are biologic medications that inhibit interleukin 17. Both secukinumab and ixekizumab are indicated to treat ankylosing spondylitis. Doctors administer both of the interleukin 17-inhibiting medications as subcutaneous injections.
Oral or injectable corticosteroids (cortisone) are potent anti-inflammatory agents and can effectively control spondylitis and other inflammations in the body. Unfortunately, corticosteroids can have serious side effects when used on a long-term basis. So they are typically used for short periods when possible. These side effects include cataracts, thinning of the skin and bones (osteoporosis), easy bruising, infections, diabetes, and destruction of large joints, such as the hips.
Inflammation and diseases in other organs are treated separately. For example, inflammation of the iris of the eyes (iritis or uveitis) may require cortisone eyedrops (Pred Forte) and high doses of cortisone by mouth. Additionally, atropine eyedrops are often given to relax the muscles of the iris. Sometimes injections of cortisone into the affected eye are necessary when the inflammation is severe. Heart disease in patients with ankylosing spondylitis, such as heart block, may require a pacemaker placement or medications for congestive heart failure.
Finally, orthopedic surgery may be required when there is severe disease of the hip joints and spine.
What is the prognosis for patients with ankylosing spondylitis?
The outlook for patients with ankylosing spondylitis is very much dependent upon the location and severity of its manifestations. The prognosis is best for those who maintain close monitoring with the treating doctors and who incorporate physical activities designed to maintain mobility. Quitting smoking is essential for the best long-term outcome. It has been found that people with ankylosing spondylitis have somewhat of an increased health risk for coronary artery disease. This increased risk appears to be caused by chronic inflammation. Therefore, it is important to optimize all modifiable cardiac risks, including elevated blood pressure and cholesterol.
Is it possible to prevent ankylosing spondylitis?
There is no prevention for this inherited (genetic) disease. Prevention measures are directed toward preventing complications of the disease with optimal treatments and monitoring for side effects of the treatments. Exercise can help to maintain flexibility.
Does ankylosing spondylitis shorten life expectancy?
Life expectancy for ankylosing spondylitis is the same as the general population, except in those with very severe disease. Ankylosing spondylitis patients with the most serious form of disease, or who develop certain complications, can have a shortened life expectancy.
What is in the future for patients with ankylosing spondylitis?
Ankylosing spondylitis and each of the spondyloarthropathies are areas of active health research. The relationship between infectious agents and the triggering of chronic inflammation is vigorously being pursued. Factors that perpetuate "autoimmunity" are being identified. The characteristics of the gene marker HLA-B27 are being further defined. In fact, there are now known to be seven different subtypes of HLA-B27.
The impact of the recent discovery of the two additional genes, ARTS1 and IL23R, associated with ankylosing spondylitis (described above under "Causes") cannot be overstated. These genes seem to play a role in influencing immune function. It is anticipated that by understanding the effects of each of these known genes researchers will make significant progress in discovering a cure for ankylosing spondylitis.
Research into other medications to treat ankylosing spondylitis is ongoing. Tofacitinib (Xeljanz) is an immunosuppressive medication currently approved to treat rheumatoid arthritis and other conditions.
Currently, tofacitinib is under investigation for the treatment of ankylosing spondylitis.
As more about the precise mechanisms these genes use to influence the immune system is understood, the discovery of a cure will be possible. Moreover, results of ongoing research will lead to a better understanding and optimal treatment options of the entire group of diseases collectively known as spondyloarthropathies.
Where can people find more information about ankylosing spondylitis and learn about support groups?
For more information about ankylosing spondylitis, please visit the Arthritis Foundation (http://www.arthritis.org/) and contact local branches of the Arthritis Foundation and/or Spondylitis Association of America for support group information.