How do biologics help manage ankylosing spondylitis symptoms. What are the different types of biologics available for treating AS. Are there potential risks or side effects associated with biologic medications for ankylosing spondylitis. How do biologics compare to other treatment options for AS.

Understanding Ankylosing Spondylitis and Its Treatment Options

Ankylosing spondylitis (AS) is a chronic inflammatory condition that primarily affects the spine and sacroiliac joints. For many individuals living with AS, medication plays a crucial role in managing symptoms and slowing disease progression. This article delves into the various medication options available for AS treatment, with a particular focus on biologic drugs.

The Role of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) in AS Management

NSAIDs are often the first line of defense against ankylosing spondylitis pain. These medications help reduce inflammation and alleviate pain and stiffness associated with AS. There are three main categories of NSAIDs used in AS treatment:

• Over-the-counter NSAIDs (e.g., aspirin, ibuprofen, naproxen)
• Prescription NSAIDs (stronger doses of OTC medications)
• COX-2 inhibitors (e.g., celecoxib, available by prescription only)

While NSAIDs can be effective in managing AS symptoms, they may not be sufficient for all patients, especially those with more severe disease activity. In such cases, healthcare providers may recommend more potent medications, such as biologics.

Biologics: A Game-Changer in Ankylosing Spondylitis Treatment

Biologic medications have revolutionized the treatment of ankylosing spondylitis by targeting specific components of the immune system responsible for inflammation. These drugs can help suppress immune system activity, thereby reducing AS disease activity and symptoms.

How do biologics work in treating ankylosing spondylitis?

Biologics for AS primarily fall into two categories:

1. TNF inhibitors (TNF blockers)
2. Interleukin (IL) inhibitors

These medications can potentially:

• Slow the progression of ankylosing spondylitis
• Treat peripheral joint pain
• Alleviate spinal arthritis pain

FDA-Approved Biologics for Ankylosing Spondylitis

Currently, there are six FDA-approved biologic medications for the treatment of ankylosing spondylitis:

1. Etanercept (Enbrel)
2. Infliximab (Remicade)
3. Adalimumab (Humira)
4. Golimumab (Simponi)
5. Certolizumab (Cimzia)
6. Secukinumab (Cosentyx)

These medications are administered via injection or infusion, with dosing schedules varying depending on the specific drug and patient needs. Some patients may require weekly injections, while others may receive infusions every six weeks.

The Promise of Oral Biologics in AS Treatment

Researchers are exploring a new class of drugs called Janus kinase (JAK) inhibitors, which can be taken orally. In 2016, the FDA approved tofacitinib citrate (XelJanz) for rheumatoid arthritis, and some experts believe it may also be effective in treating other autoimmune diseases, including ankylosing spondylitis.

Can oral biologics offer a more convenient treatment option for AS patients?

Oral biologics have the potential to provide a more convenient administration method for patients compared to injectable or infusible biologics. However, more research is needed to establish their efficacy and safety specifically for ankylosing spondylitis.

Potential Risks and Side Effects of Biologic Medications

While biologics can be highly effective in managing AS symptoms, they do come with potential risks and side effects. The most significant concern is an increased risk of infections due to the suppression of the immune system.

What are the most common side effects of biologics used in AS treatment?

Common side effects of biologic medications may include:

• Injection site reactions
• Upper respiratory infections
• Headaches
• Nausea
• Fatigue

It’s crucial for patients to discuss potential risks and side effects with their healthcare provider before starting biologic therapy. Regular monitoring and follow-up appointments are essential to ensure the medication’s safety and efficacy.

Comparing Biologics to Other AS Treatment Options

While biologics have shown great promise in managing ankylosing spondylitis, they are not the only treatment option available. Other medications used in AS management include:

Steroids

Steroids may be used to control painful eye symptoms associated with AS or injected directly into painful joints. Oral steroids, such as prednisone, are rarely used for long-term AS treatment due to potential side effects.

Disease-Modifying Antirheumatic Drugs (DMARDs)

DMARDs, such as methotrexate and sulfasalazine, may be prescribed to people whose ankylosing spondylitis causes peripheral joint pain (e.g., pain in the knees, hips, or ankles). However, DMARDs are generally not effective in treating axial joint pain, including pain in the neck, back, and sacroiliac joint.

How do biologics compare to DMARDs in treating ankylosing spondylitis?

Biologics are often considered more effective than traditional DMARDs for managing AS symptoms, particularly for patients with axial involvement. However, the choice between biologics and DMARDs depends on various factors, including disease severity, patient preferences, and potential side effects.

The Importance of Individualized Treatment Plans for AS Patients

Ankylosing spondylitis is a complex condition that affects each patient differently. As such, treatment plans should be tailored to individual needs and circumstances.

What factors do healthcare providers consider when developing an AS treatment plan?

When creating a treatment plan for ankylosing spondylitis, healthcare providers take into account several factors, including:

• Disease severity and progression
• Presence of peripheral joint involvement
• Comorbid conditions
• Patient age and overall health
• Previous treatment responses
• Patient preferences and lifestyle considerations

By carefully considering these factors, healthcare providers can develop a personalized treatment approach that maximizes efficacy while minimizing potential risks and side effects.

The Future of Ankylosing Spondylitis Treatment: Emerging Therapies and Research

As our understanding of ankylosing spondylitis continues to grow, researchers are exploring new treatment options and refining existing therapies. Some areas of ongoing research include:

Novel Biologic Targets

Scientists are investigating new biological pathways involved in AS inflammation, which may lead to the development of more targeted and effective biologic medications.

Combination Therapies

Researchers are studying the potential benefits of combining different types of medications, such as biologics with traditional DMARDs, to enhance treatment efficacy.

Personalized Medicine Approaches

Advances in genetic and biomarker research may help identify which patients are most likely to respond to specific treatments, allowing for more tailored therapeutic strategies.

What promising developments are on the horizon for AS treatment?

Some exciting areas of research in ankylosing spondylitis treatment include:

• Development of new IL-17 and IL-23 inhibitors
• Investigation of gut microbiome’s role in AS and potential probiotic therapies
• Exploration of stem cell therapies for tissue regeneration in advanced AS
• Refinement of biologic drug delivery methods for improved patient convenience and adherence

As research progresses, patients with ankylosing spondylitis can look forward to an expanding array of treatment options and improved quality of life.

The Role of Patient Education and Self-Management in AS Treatment Success

While medications play a crucial role in managing ankylosing spondylitis, patient education and self-management strategies are equally important for achieving optimal outcomes.

How can patients actively participate in their AS treatment plan?

Patients can take an active role in their AS management by:

• Staying informed about their condition and treatment options
• Adhering to prescribed medication regimens
• Engaging in regular exercise and maintaining good posture
• Practicing stress management techniques
• Maintaining a healthy diet and lifestyle
• Communicating openly with their healthcare team about symptoms and concerns

By combining effective medication strategies with proactive self-management, patients with ankylosing spondylitis can significantly improve their quality of life and potentially slow disease progression.

Navigating Insurance Coverage and Cost Considerations for Biologic Therapies

One of the significant challenges associated with biologic medications for ankylosing spondylitis is their high cost. Many patients may face difficulties obtaining insurance coverage or managing out-of-pocket expenses for these treatments.

How can patients address the financial aspects of biologic therapy for AS?

Patients can explore several options to manage the cost of biologic medications:

• Work closely with their healthcare provider to document medical necessity for insurance approval
• Investigate patient assistance programs offered by pharmaceutical companies
• Explore biosimilar options, which are typically less expensive than brand-name biologics
• Consider participating in clinical trials for access to new treatments at reduced or no cost
• Discuss alternative treatment options with their healthcare provider if biologic therapy is not financially feasible

By addressing these financial considerations, patients can work towards accessing the most appropriate and effective treatments for their ankylosing spondylitis.

The Importance of Regular Monitoring and Follow-up in AS Treatment

Regardless of the chosen treatment approach, regular monitoring and follow-up are essential components of successful ankylosing spondylitis management.

Why is ongoing assessment crucial for patients on biologic therapy?

Regular monitoring allows healthcare providers to:

• Assess treatment efficacy and make necessary adjustments
• Detect and address potential side effects or complications early
• Monitor disease progression and adjust treatment strategies as needed
• Evaluate the need for additional interventions or supportive therapies
• Ensure patient safety and optimize long-term outcomes

Patients should maintain open communication with their healthcare team and attend scheduled follow-up appointments to ensure the best possible management of their ankylosing spondylitis.

Ankylosing Spondylitis Medications | Arthritis-health

Watch: Ankylosing Spondylitis Video

Many people who have ankylosing spondylitis take medications to help reduce the inflammation that causes pain and stiffness. What type of medication a doctor recommends will depend on the person’s symptoms and their severity.

There are four types of medications commonly used to treat ankylosing spondylitis: Nonsteroidal anti-inflammatory drugs (NSAIDs), biologics, steroids, and DMARDs. Like all medications, these drugs can cause side effects or interact with other medications. Patients are advised to discuss any drug therapy plan with their health care professional and report side effects.

advertisement

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are often the first line of defense against ankylosing spondylitis pain. NSAIDs is a broad category of medications that includes:

1. Over the counter NSAIDs, such as aspirin, ibuprofen, and naproxen.
2. Prescriptions NSAIDs, which have the same ingredients as over-counter-medications but are packaged in stronger doses.
3. COX-2 inhibitors, sometimes called coxibs, which are available only by prescription. Celecoxib, sold as Celebrex, is a COX-2 inhibitor.

See Pain Medications for Arthritis Pain Relief

Biologics

Biologic medications suppress immune system activity, thereby decreasing ankylosing spondylitis disease activity and symptoms. In some people, biologic drugs called TNF-inhibitors (TNF-blockers) as well as certain interleukin (IL) inhibitors appear to do one or more of the following:

• Slow the progression of the ankylosing spondylitis
• Treat peripheral joint pain
• Treat spinal arthritis pain

See Biologics: Basic Facts for Patients

Biologic medications are administered with a needle, either injected under the skin or infused into a vein. Exactly how much and how often a medication must be administered varies significantly depending on the drug and the patient. Some ankylosing spondylitis patients may take medication once a week, while others get an infusion once every 6 weeks.

See The Science Behind Biologics

Currently, there are six FDA-approved biologic medications for ankylosing spondylitis:

• Etanercept (Enbrel)
• Infliximab (Remicade)
• Adalimumab (Humira)
• Golimumab (Simponi)
• Certolizumab (Cimzia)
• Secukinumab (Cosentyx)

These biologic medications are expensive. In addition, they carry potential risks and side effects, including possible infections resulting from a suppressed immune system.

See Risks and Side Effects of Biologics

Oral biologics
Researchers are studying a class of drugs called Janus kinase (JAK) inhibitors, which can be taken orally. In 2016, the FDA approved the JAK inhibitor tofacitinib citrate (XelJanz) for rheumatoid arthritis. Some experts believe it may also be effective in treating other autoimmune diseases, including as ankylosing spondylitis.

See Biologics, Biosimilars, and Interchangeable Biosimilars—What is the Difference?

In This Article:

• What Is Ankylosing Spondylitis?

• Ankylosing Spondylitis Causes and Risk Factors

• Ankylosing Spondylitis Symptoms

• Complications of Severe Ankylosing Spondylitis

• Ankylosing Spondylitis Diagnosis

• Ankylosing Spondylitis Treatment

• Ankylosing Spondylitis Medications

• Ankylosing Spondylitis Surgery

• Ankylosing Spondylitis Video

Steroids

Steroids may be used to control painful eye symptoms or injected into painful joints. Oral steroids, such as oral prednisone, are rarely used to treatment AS or other spondyloarthropathies.

See Cortisone Injections (Steroid Injections)

Disease-modifying antirheumatic drugs (DMARDs)

DMARDs, such as methotrexate and sulfasalazine, may be prescribed to people whose ankylosing spondylitis causes peripheral joint pain, such as pain in the knees, hips or ankles. DMARDs are not effective in treating pain doctors call axial joint pain, including pain in the neck, back, and sacroiliac joint.

¹
Disease Modifying Anti Rheumatic Drugs (DMARDS). National Ankylosing Spondylitis Society. http://nass.co.uk/about-as/living-well-with-as/medication-for-as/disease-modifying-anti-rheumatic-drugs-dmards/

See Sacroiliac Joint Pain and Inflammation

DMARD side effects may include but are not limited to headaches, abdominal bloating, and nausea/vomiting. Patients can develop bone marrow suppression and/or liver toxicity, so it is important for doctors to regularly monitor patient’s blood samples.

advertisement

Medications May Change Over Time

Most newly-diagnosed patients are started on NSAID medications. If symptoms are not alleviated within a reasonable window of time, or if the case is severe, the doctor may recommend using another type of medication, usually a biologic. Over months or years, a medication may become less effective or cause unacceptable side effects, and a new medication can be prescribed.

Dr. Judith Frank is a rheumatologist and internal medicine physician. She has been practicing for nearly 30 years, specializing in osteoarthritis, rheumatoid arthritis, gout, and lupus. She completed her Doctor of Medicine degree, residency, and fellowship training from Rush University.

• 1
  Disease Modifying Anti Rheumatic Drugs (DMARDS). National Ankylosing Spondylitis Society. http://nass.co.uk/about-as/living-well-with-as/medication-for-as/disease-modifying-anti-rheumatic-drugs-dmards/

• Share on Facebook
• Share on Pinterest
• Share on Twitter
• Subscribe to our newsletter

• Email this article

advertisement

Editor’s Top Picks

• Arthritis Treatment Specialists

• Cortisone Injections (Steroid Injections)

• 5 Unusual Ankylosing Spondylitis Symptoms

• Risks and Side Effects of Biologics

• Biologics: Basic Facts for Patients

• Ankylosing Spondylitis Video

Treating Ankylosing Spondylitis With Biologics

In this Article

Your doctor may prescribe certain treatments, like nonsteroidal anti-inflammatory drugs and physical therapy, to help your ankylosing spondylitis. But everyone is different: What works for someone else might not work for you. If this happens, your doctor will most likely recommend that you try a new class of drugs known as biologics.

“These are amazing drugs that have really revolutionized how we treat this disease,” says Yale Medicine rheumatologist Deborah Desir, MD.

Though they won’t magically cure your ankylosing spondylitis, they can help slow the disease’s progression and make symptoms more manageable.

How Do Biologics Work?

Biologics stop the damaging inflammation that happens with ankylosing spondylitis.

“They’re genetically engineered proteins that target cytokines, specific molecules in your immune system,” says Lianne Gensler, MD, director of the University of California San Francisco’s Ankylosing Spondylitis Clinic.

Cytokines activate inflammation throughout your body, which keeps your immune system on its toes to fight off invaders. But if they go into overdrive, they can trigger inflammatory diseases such as ankylosing spondylitis.

There are two main classes of biologics used to treat ankylosing spondylitis:

Tumor necrosis factor alpha (TNF-α) inhibitors. These were the first approved in 2003. They work not only to ease joint inflammation, but related inflammation in the gut and eyes as well. There are five approved for ankylosing spondylitis:

• Adalimumab (Humira)
• Certolizumab (Cimzia)
• Entanercept (Enbrel)
• Golimumab (Simponi)
• Infliximab (Remicade)

IL-17 inhibitors. Two are FDA-approved for ankylosing spondylitis: ixekizumab (Taltz) and secukinumab (Cosentyx). They target different cytokines than the TNF inhibitors. They’re often used in people whose ankylosing spondylitis didn’t respond to several of the TNF medications.

Who Should Take Biologics?

While biologics are very effective, they’re not for everyone.

“These drugs are very powerful, but they also suppress the immune system, which means you’re more vulnerable to infection,” Gensler says. Because of this, most doctors hold off using them right away.

When you’re newly diagnosed with ankylosis spondylitis, your doctor will most likely start you on a course of nonsteroidal anti-inflammatory drugs (NSAIDS). These include over-the-counter versions such as ibuprofen, as well as prescription-strength drugs like celecoxib (Celebrex).

“These drugs are the most common ones we use, and for good reason: a huge percentage of patients are able to get control of their symptoms on them,” Desir says.

They’ll also prescribe physical therapy to help ward off the “frozen” spine and general stiffness that can occur with ankylosis spondylitis.

The downside of NSAIDs is that to stay symptom-free, most people need very high doses. Over time, this can lead to side effects such as stomach bleeding and higher risk of heart attack or stroke.

“We’re most worried about these side effects in older adults, since they are the ones who are already at risk for these diseases. But for a younger patient in their 20s or 30s newly diagnosed with the condition, that’s much less of a concern,” Gensler says. “We don’t have long-term safety data on biologics yet beyond about 2 decades, so it’s still unknown what the effects of these drugs would be on patients who are on them for most of their lives. That’s why we’d prefer to start with an NSAID, and then escalate if need be.”

In general, Gensler says you should consider a biologic if:

• You’ve tried a course of NSAIDs and physical therapy for a few weeks and are still bothered by symptoms.
• Your X-rays already show that you have a lot of damage to your sacroiliac joints, the joints that connect your spine to your pelvic bone.
• You’ve already lived with ankylosis spondylitis for a long time.

It can sometimes take up to 10 years for people to be diagnosed with this condition.

“Sometimes patients come in for the very first visit in extreme pain and very disabled, and they say that their quality of life is terrible and they’d do anything to get it back to where they can function again,” Gensler says.

What Should I Expect When I Take a Biologic?

If you and your doctor agree biologics are the next step, they’ll test you for tuberculous first.

“Some people have what’s known as latent TB, where the bacteria live silently in their lungs,” Desir says. “Since these drugs suppress your immune system, the TB can ‘wake up’ and cause an actual infection.”

All biologic treatments leave you more prone to infection, especially upper respiratory infections such as colds, flu, or COVID-19. To stay healthy, you should:

• Wash your hands often
• Avoid or wear a mask in crowded areas, enclosed spaces, public transportation, and childcare facilities
• Keep up to date on all your vaccines, including the flu and COVID-19 vaccines.

Some biologics are given at home via self-injection, and others are given through an IV in your doctor’s office. You may notice some pain, redness, and swelling. You can use antihistamines and an over-the-counter pain reliver such as acetaminophen to treat discomfort.

If you’re on the fence about trying a biologic, Gensler suggests giving it a 3-month trial.

“I stress to (people) that this does not have to be a lifetime commitment. They can always go off of the biologic and return to their original medications,” she says. “But oftentimes, after a few months, people are shocked at how much better they feel. They’ve suffered for so long they’ve just accepted their symptoms as normal. But thanks to biologics, it doesn’t have to be that way anymore.”

© 2022 WebMD, LLC. All rights reserved.

Photo Credit: KATERYNA KON / SCIENCE PHOTO LIBRARY/ Getty Images

SOURCES:

Deborah Desir, MD, associate professor of clinical medicine, Yale School of Medicine.

Lianne Gensler, MD, director, University of California San Francisco’s ankylosing spondylitis clinic.

UptoDate: “Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics).”

Spondylitis Association of America: “Medications Used to Treat Ankylosing Spondylitis and Related Diseases. ”

Arthritis Foundation: “Biologics.”

American Journal of Managed Care: “Epidemiology of Axial Spondyloarthritis.”

Annals of Rheumatic Diseases: “Diagnosis journey of patients with ankylosing spondylitis in the united states.”       

Modern principles of therapy for ankylosing spondylitis | Kimova A.M.

The article presents modern principles of therapy for ankylosing spondylitis

For citation. Kimova A.M. Modern principles of therapy for ankylosing spondylitis // RMJ. 2015. No 25. S. 1499–1503.

Ankylosing spondylitis (AS) (Bekhterev’s disease, Strümpel-Marie-Bekhterev’s disease) is a chronic inflammatory disease of the spine (spondylitis), sacroiliac joints (sacroiliitis), often peripheral joints (arthritis), enthesis (enthesitis), in some cases – eyes (uveitis), cardiovascular system – aortic root (aortitis), other internal organs.
This disease was known in ancient Egypt. The first descriptions of AS in foreign literature were made by A. Strümpel (1884) and P. Marie (1898) and were regarded as a variant of chronic articular rheumatism [1]. In the domestic literature, priority is given to V.M. Bekhterev, although the clinical picture of patients with “stiffness of the spine”, described by Bekhterev, differed from the classical AS clinic. However, V.M. Bekhterev drew great attention to the problem of AS, which served as an impetus for the study of AS and other spondyloarthritis [2].

Classification modified New York criteria for the diagnosis of AS (1984):
1. Pain and stiffness in the lower back – more than 3 months, decreasing after exercise and aggravated at rest.
2. Limitation of movements in the lumbar spine in the sagittal and frontal planes.
3. Decreased chest excursion (compared to normal values ​​for gender and age).
4. Bilateral sacroiliitis 2-4 stages or unilateral sacroiliitis 3-4 stages.
The diagnosis of definite AS is established in the presence of radiological and at least 1 clinical criterion [3].
The disease can begin in childhood, but the peak falls on the 3rd decade (usually no later than 40 years). Men get sick 2-3 times more often than women. In more than 90% of cases, the genetic marker HLA-B27 is detected. Despite the fact that the clinical picture of AS was described half a century ago, the diagnosis of AS is established, on average, 7–10 years after the onset of the first manifestations. This is due to a number of reasons such as:
– variety of the clinical picture at the onset of the disease;
– non-vertebral lesions, in connection with which patients turn to various specialists;
– slow development of radiographic signs of sacroiliitis, which are of decisive importance;
– spontaneous long-term remissions in the first years of the disease;
– absence of immunological markers;
– non-permanent increase in ESR and CRP in the first months and years of AS;
– lack of sufficient knowledge about the debut of AS among doctors of other specialties.
The clinical picture of AS does not depend on gender and the presence of HLA-B27. In about 25% of cases, the disease appears in childhood. Not always AS begins with spondylitis or sacroiliitis.

Variants of disease onset

Spinal injury
Damage to the spine usually begins with the sacroiliac joints with a gradual transition to the overlying sections. Sacroiliitis is manifested by intermittent pain in the buttocks, radiating to the gluteal folds, along the back of the thigh, to the inguinal region. Gradually, the pain increases, becomes bilateral. Inflammatory pain in the lower back is also characteristic of the early stage of the disease, for the diagnosis of which the following criteria have been developed:
– age of onset of pain – earlier than 40 years;
– gradually increasing current;
– reduction of pain after exercise;
– lack of improvement at rest;
– night pain.
Pain is considered inflammatory if 4 out of 5 signs are present. With AS, all parts of the spine are involved in the process. The disease often occurs under the guise of lumbosacral sciatica. With damage to the thoracic spine, costovertebral joints, there is pain in the chest, sometimes girdle character. The pain is aggravated by coughing, taking a deep breath, turning. The defeat of the costovertebral joints helps to reduce the excursion of the chest, which further leads to a decrease in the vital capacity of the lungs. The defeat of the cervical spine occurs at a later date and leads to a decrease in the volume of movement of the head and neck. Cervical spondylitis may be accompanied by symptoms of discirculatory encephalopathy. Pain in the spine reflexively causes muscle spasm, which leads to limited mobility of the spine. In the early stages of the disease, the limitation of the range of motion in the spine is due to inflammation and reflex spasm of the muscles against the background of pain; at the stage of advanced clinical manifestations, movements are limited due to ossification of the spine. Over time, as a result of an inflammatory lesion of the spine, changes in posture occur that are characteristic of AS: the posture of the “beggar”, the posture of the “proud”.

Peripheral joint disease
Peripheral arthritis is noted throughout the disease in more than half of patients and begins mainly with the joints of the lower extremities. The most commonly affected are the hip, knee, ankle joints, less often the temporomandibular, metatarsophalangeal, and shoulder joints. Peripheral arthritis of any localization is a serious problem due to severe pain, as well as due to the destruction of the articular surfaces and dysfunction. The most unfavorable in terms of prognosis is coxitis, often bilateral. It often develops in patients who fell ill in childhood [8]. Peripheral arthritis in AS is often associated with enthesitis.

Enthesites
Inflammation of entheses in AS is natural. In AS, enthesitis is manifested by pain during movement, in which the corresponding tendon is involved, soreness, and sometimes swelling of the area of ​​enthesis. Enthesitis usually appears in the heel, elbow, knee, shoulder and hip joints. The underlying bone (osteitis) is involved in the inflammatory process, which leads to the development of erosions and further ossification and excessive bone formation. These phenomena underlie the appearance of peculiar radiographic changes characteristic of AS: extra-articular bone erosion, subchondral osteosclerosis, bone proliferation (“spurs”) and periostitis. In AS, extraskeletal lesions are observed: uveitis, changes in the aorta and heart, kidney damage.

Uveitis
The frequency of uveitis in systemic rheumatic diseases ranges from 25 to 50%. Uveitis is the most common extraskeletal manifestation of AS; it can be a manifestation and for a long time the only manifestation of the disease. Uveitis begins acutely and lasts up to 3 months, has a recurrent character, can affect all parts of the uveal tract. Both eyes can be involved alternately in the process. Patients have pain in the eye, photophobia, lacrimation, conjunctival hyperemia. The development of complications leads to a decrease in vision and blindness at a young, working age. Blindness and low vision can account for 10 to 35% of eye diseases [9].

Damage to the heart and aorta
Damage to the heart and aorta determines the prognosis of the disease and the tactics of therapeutic measures. It is known that there is no relationship between activity and severity of damage to the musculoskeletal system. Despite the fact that damage to the cardiovascular system often proceeds subclinically, damage to the aorta and aortic valves is found in 24–100% of cases on section [4, 11].
Early diagnosis of AS allows avoiding unnecessary examinations and protecting patients from improper therapy, including surgical manipulations, orienting the patient to the systematic use of non-steroidal anti-inflammatory drugs (NSAIDs), and in case of an unfavorable prognosis of AS, prescribing tumor necrosis factor inhibitors (anti- TNF-therapy) at an early stage. Training in physiotherapy exercises and a healthy lifestyle contributes to a more favorable outcome of AS.

Treatment of AS
It should be based on the clinical signs of the disease present at the time of examination (vertebral, articular, enthesis symptoms), their severity, the presence of prognosis indicators: disease activity / inflammation, functionality / disability, structural damage, involvement of the hip joints, spinal deformity, general clinical status (age , gender, comorbidities and therapy), patient expectations and preferences. The management of a patient with AS requires a mandatory combination of non-pharmacological and pharmacological methods of treatment.

Non-drug treatments
Non-drug methods of treatment include daily performance of a set of physical exercises aimed at maintaining a sufficient range of motion in the spine and large joints, strengthening skeletal muscles [12]; breathing exercises, back massage, physiotherapeutic procedures with various anti-inflammatory ointments in the form of phonophoresis, balneotherapy: radon and hydrogen sulfide baths. The functional state of the spine in people who regularly engage in exercise therapy and muscle training is better than in patients who neglect exercise for one reason or another. Non-pharmacological methods for AS may include educational programs – schools for patients. They can be done both individually and in groups. Non-pharmacological treatments for AS are only of secondary importance.

Pharmacological treatments
Pharmacological methods of treatment combine drugs from several groups: NSAIDs, muscle relaxants, corticosteroids, anti-TNF therapy.
NSAIDs
Despite the long history of the use of NSAIDs in the practice of rheumatology, in the current EULAR/ASAS recommendations, they are still first-line drugs in the treatment of AS, since they are distinguished by a unique combination of analgesic, anti-inflammatory, and antipyretic effects [5]. The long-term use and high efficacy of NSAIDs in relation to inflammatory pain raises the question of their ability to have not only symptomatic, but also disease-modifying effects, i. e., slowing radiographic progression. A recent observation by A. Wanders et al. confirmed that NSAIDs can slow down radiological progression (ossification) in the spine. According to this study, it turned out that the average values ​​of radiological changes were significantly less in patients who took NSAIDs constantly, and not on demand. However, it has not been established what influences the slowing down of spinal ossification: the suppression of active inflammation or the direct effect of NSAIDs on bone tissue – the suppression of osteoblast activity. According to morphological studies, inflammation in the area of ​​enthesis and bone (osteitis) in AS continues throughout the entire disease and does not tend to completely subside even when ankylosing of the spine or joint occurs, which is the basis for long-term use of this group of drugs. After establishing the diagnosis of AS (regardless of the stage of the disease), NSAIDs should be administered to the patient immediately. AS is the only rheumatological disease in which long-term use of NSAIDs is pathogenetically justified, highly effective and has no alternative, except for TNF-a inhibitors. The first goal of prescribing NSAIDs is to relieve pain. This is usually achieved within 2 weeks. If the main symptoms of the disease are night pain in the spine and morning stiffness, then it is desirable to prescribe prolonged forms of drugs. Sometimes, to eliminate pain and morning stiffness, a sequential change of 2-3 drugs is necessary.
The most effective drugs for the treatment of AS are the classic (standard) drugs: diclofenac, indomethacin, ketoprofen, naproxen. However, the frequency of adverse reactions in this group of drugs, especially with long-term use, which is required in the treatment of AS, makes preference for selective COX-2 inhibitors. In turn, moderately selective (meloxicam, nimesulide, nabumetone, etodolac) and highly selective (celecoxib, valdecoxib, etoricoxib, lumirocoxib) stand out among the latter. The choice of drug should be based on an analysis of the advantages and disadvantages of various groups of NSAIDs, taking into account the presence of analgesic, anti-inflammatory effects in combination with good tolerability (safety in relation to the gastrointestinal tract (GIT) and the cardiovascular system). In Russia, many experts consider nimesulide (Nise) to be a drug with these properties. The advantages of this drug are also noted by many world experts. In an article dedicated to the 25th anniversary of the use of nimesulide in Italy, C. Mattia et al. pointed to the obvious predominance of the positive qualities of this drug [6]. These conclusions are confirmed by clinical studies of scientists from NIIR them. V.A. Nasonova – A.E. Karateev et al. Retrospective analysis of the incidence of complications from the gastrointestinal tract, cardiovascular system and liver in patients admitted to the NIIR from 2007 to 2008 and taking nimesulide at a dose of 200 mg for at least 12 months. before admission, showed that in addition to effective analgesic, anti-inflammatory properties, the drug Nise has good tolerance. Nimesulide has proven to be an effective pain reliever. It has high bioavailability – within 30 minutes after oral administration, a significant concentration of the drug in the blood is reached, which is at least 25% of the maximum. The full analgesic and anti-inflammatory effect of nimesulide occurs 1-3 hours after administration.
As is known, the pharmacological action of all NSAIDs is associated with the blockade of COX-2, and the gastrointestinal complications associated with their use are mainly determined by the suppression of COX-1 activity in the gastrointestinal mucosa. But COX-1 is also involved in the development of inflammation, and therefore a local decrease in its activity in the area of ​​damage should be considered as a positive factor. Nimesulide has such an effect – it only slightly affects the “structural” COX-1 of the gastric mucosa, but significantly reduces the effects of this enzyme in the area of ​​inflammation. Recently, the question of the central effects of NSAIDs associated with their ability to penetrate the tissue of the central nervous system and influence the development of a number of links in the pathogenesis of chronic pain associated with the activation of the central pain system (the phenomenon of “central sensitization”) has been actively discussed. Nimesulide obviously has such an effect, which is confirmed by the data of experimental and clinical studies. There is good reason to believe that nimesulide has a number of pharmacological effects independent of class-specific effects on COX-2. In particular, it suppresses the hyperproduction of the main pro-inflammatory cytokines (interleukin-6, TNF-a), reduces the activity of metalloproteinases.
The effectiveness of nimesulide for the relief of acute and chronic pain in rheumatic diseases (RD) is confirmed by a series of clinical trials. Thus, there is evidence of its use in postoperative pain relief. In acute rheumatic inflammation of the periarticular soft tissues – enthesitis, bursitis and tendonitis, it demonstrates a good therapeutic effect, comparable or more pronounced than the effect of high doses of “traditional” NSAIDs – diclofenac and naproxen. In particular, W. Wober et al. conducted a study in which 122 patients with subacromial bursitis and tendonitis took nimesulide 200 mg/day or diclofenac 150 mg/day for 14 days. At the same time, a “good” or “excellent” response to treatment was somewhat more often observed in persons taking nimesulide – 82.3%, compared with 78.0% in the diclofenac group. A subjective assessment of the tolerance of the drugs used showed an even more pronounced advantage of nimesulide: 96.8% of patients rated its tolerability as “good” or “excellent”, while only 72.9% gave a similar assessment to diclofenac [14].
Nimesulide is effective for acute low back pain (LBP). According to a clinical trial conducted by Finnish scientists, nimesulide at a dose of 100 mg 2 times a day was superior to ibuprofen at a dose of 600 mg 3 times a day, both in terms of the severity of the analgesic effect and in restoring the function of the spine. By the 10th day of therapy, the use of nimesulide provided an improvement in functional activity by more than 2 times. This makes nimesulide (Nise) very attractive for the treatment of pain in Bechterew’s disease.
One of the most valuable advantages of nimesulide for clinical practice is its good gastrointestinal tolerance. After all, it is the development of the pathology of the digestive system, which is one of the class-specific complications of NSAIDs, that is one of the main parameters that determine the risk-benefit ratio for this class of painkillers.
The risk of liver complications when using nimesulide (Nise) is not higher than that of “traditional” NSAIDs. An analysis of the available literature data and clinical studies shows that the negative dynamics of laboratory biochemical parameters, indicating the development of liver pathology, is observed with the use of nimesulide with the same frequency as with other NSAIDs. When analyzing reports of hepatotoxic reactions, it turned out that the total number of reports when using diclofenac was 990, ibuprofen – 590, and nimesulide – only 152. Most importantly, a life-threatening pathology – liver failure was recorded by WHO in 21 patients who received diclofenac, and in 32 patients who received ibuprofen. Against the background of taking nimesulide, this complication was noted only in 4 cases. It becomes clear that complications from the liver when using nimesulide are extremely rare, and their absolute number in comparison with other popular NSAIDs is very small.
In 2013, the absence of specific hepatotoxicity of nimesulide was confirmed by another population-based study. S. Gulmez et al. studied the causes of acute liver failure in 9479 people included in the list in need of emergency liver transplantation (European Union, 2005–2007). NSAIDs were the etiological factor of this potentially fatal complication in 40 cases, paracetamol – in 192. The relative risk (RR) of acute liver failure for different drugs is different. According to the results of the study, nimesulide was less dangerous than paracetamol and ibuprofen, and actually equal to such drugs as diclofenac and ketoprofen. In Russia, not a single case of severe hepatotoxic reactions has been described [7].
An important factor contributing to the popularity of nimesulide among other drugs of this drug group is its low cost, which makes it affordable for the vast majority of the inhabitants of our country. After all, the main consumers of NSAIDs are patients suffering from chronic diseases of the joints and spine, elderly people with low income.
In addition to standard forms for oral administration, a preparation for local use is also presented – Nise gel containing 1% of the active substance. Local forms of NSAIDs are a useful and safe agent that can be used for adjuvant therapy both when applied to the skin and in the form of phonophoresis with an ointment on the painful area [13].
Glucocorticosteroids (GCS)
For the treatment of AS, systemic use of corticosteroids is not recommended. But these drugs are effective as local therapy for peripheral arthritis in recurrent synovitis. The effectiveness of HA in the treatment of AS is beyond doubt, but they are less effective in the treatment of enthesitis (apparently due to the lower concentration of the active substance in the avascular zone of enthesis). In these cases, local injections of corticosteroids into the enthesis zone are highly effective.
Muscle relaxants
It is known that pain in the spine is accompanied by muscle spasm, the presence of which in turn exacerbates pain and spasm. It has been established that the simultaneous use of NSAIDs and muscle relaxants reduces back pain and also helps to maintain spinal mobility [7].
DMARDs
Synthetic DMARDs: sulfasalazine, methotrexate, leflunomide are not recommended in the treatment of axial forms of AS due to inefficiency. But in peripheral arthritis, this group of drugs is used with a positive effect, which is recommended to be evaluated no earlier than after 3 months. Sulfasalazine is taken in a daily dose of 2-3 g. The use of methotrexate, depending on the effectiveness, toxicity, can be at a dose of 10 to 15-20 mg per week and must be accompanied by folic acid intake, excluding the day of methotrexate intake. In case of intolerance to methotrexate, the patient may be prescribed Arava. The latter is taken at 20 mg/day after a 3-day induction dose of 100 mg/day for 3 days.
Genetically engineered biological products (GIBPs)
Recently, significant progress has been made in the treatment of diseases of the joints and spine due to the use of GEBP. The high efficiency of this group of drugs has been confirmed by numerous studies and long-term use in medical practice. In AS, these drugs provide a distinct reduction in pain and inflammation in the spine, joints, and entheses. Approved drugs for the treatment of AS include infliximab, adalimumab, etanercept, golimumab, and certolizumab pegol. A fundamental difference in the effectiveness of these drugs in relation to the effect on the main symptoms (pain, stiffness, enthesitis, peripheral arthritis) has not been established. Treatment with GIBD should be started if there is no effect in the treatment of both NSAIDs and NSAIDs in combination with DMARDs (sulfasalazine at a maximum dose of 3 g / day) for 3 months. The effect of TNF-a inhibitors on uveitis (as opposed to the effects on the spine and peripheral arthritis) has been little studied. A group of employees of the NIIR them. V.A. Nasonova (A.A. Godzenko, A.G. Bochkova, Sh.F. Erdes et al.) studied the effect of TNF-a inhibitors: infliximab, adalimumab, and etanercept on the frequency of uveitis attacks in patients with AS. As a result of the study, it was found that TNF-a inhibitors effectively affect uveitis in patients with AS. The three drugs studied (infliximab, adalimumab, etanercept) significantly reduced the incidence of uveitis exacerbations compared to standard anti-inflammatory therapy. The criteria for evaluating response to treatment are a global assessment of the patient’s well-being using a 100-mm visual analog scale (VAS), pain in the spine using the VAS, a functional assessment of the patient (BASFI), and an assessment of inflammation using the BASDAI questionnaire [1, 10].

Surgery
In cases of involvement in the process of the hip joints with the development of coxitis and subsequent functional disorders in patients, arthroplasty of the hip joint can be performed. Spinal surgery (corrective osteotomy) may be performed if necessary.
Despite significant progress in the treatment of AS in recent years, many unresolved problems remain: monitoring of patients, the immunogenicity of GEBAs and their impact on the efficacy and safety of therapy, etc. This leaves the tactics of managing and treating patients with AS in the focus of scientists and physicians.

Ankylosing spondylitis – symptoms, causes, treatment

Treatment of ankylosing spondylitis

Treatment of AS is a step-by-step set of therapeutic measures aimed at relieving inflammation, eliminating muscle spasm, stiffness and relieving pain. The course of treatment includes basic anti-inflammatory therapy, restoration and maintenance of the functional capacity of the joints and spine.

Massage

An important method of restorative treatment of ankylosing spondylitis is mechanical manual impact. Therapeutic massage for Bechterew’s disease often exceeds the effectiveness of pharmacotherapy, and also avoids its inherent complications. Superficial, deep stroking, kneading and displacement stimulate tissue trophism, relax tense muscles, gradually improve joint mobility, increase the functional and adaptive capabilities and quality of life of the patient. In addition to the classic, techniques of segmental paravertebral massage with weights are used. More information about massage techniques used in the treatment of ankylosing spondylitis can be found here.

Other methods of treatment

Physiotherapy methods are used to stimulate blood circulation, accelerate the resorption of inflammatory foci, inhibit degenerative processes and ankylosing. Effective: heat therapy, UV irradiation, ultrasound exposure, SMT therapy, mud, radon baths, paraffin, ozocerite, inductothermy, etc. Physiotherapy for Bechterew’s disease is supplemented by the following methods:

• medical treatment
• exercise therapy
• post-isometric relaxation
• phonophoresis
• acupuncture in local acupuncture points and broad spectrum points
• air cryotherapy
• sunbathing
• hirudotherapy (medical leeches)
• orthotics (corsets, bandages and orthoses to reduce the load on the problem area)

For severe stiffness and progressive “fossilization”, surgical correction is recommended (vertebral osteotomy or endoprosthesis of diseased joints).

Drug treatment

Pharmacotherapy of ankylosing spondylitis includes several drug groups: local injections for peripheral arthritis)

Medicines for Bechterew’s disease are used in various forms. Painkillers are prescribed strictly individually. Tablets, injections or local analgesic and anti-inflammatory drugs are selected taking into account age and safety in relation to the gastrointestinal tract and the cardiovascular system.

Exercise therapy for Bechterew’s disease

Physical therapy is an obligatory method for the prevention and rehabilitation of AS. Exercises for Bechterew’s disease are selected individually. Main tasks:

• improving the quality of lung ventilation reduced due to damage to the vertebral joints
• slowing down the progression of ankylosis
• strengthening of weakened muscles
• physical correction of the onset deformity
• stabilization or compensation of motor stereotype

9 0137 improvement of the general well-being of the patient.