Spotlight on ankylosing spondylitis

Ankylosing spondylitis (AS) is one of the most common types of inflammatory arthritis. It is estimated to affect up to 1 in 200 people.

Ankylosing spondylitis primarily affects the spine, but can also involve the hips, knees, shoulders, and rib cage. The most common symptom of AS is long-term back pain, along with spinal stiffness in the morning or after a long period of rest (this is the main reason why AS is often mis-diagnosed as ordinary "low back pain").

Unlike in many other forms of arthritis where women are most affected, three out of four people diagnosed with ankylosing spondylitis are men. It tends to strike in the prime of life; while it can strike at any age, it is most common in people between ages 15 and 40. While it has no known cure, it is treatable; with the proper care, people who are diagnosed with AS can lead full, productive lives.

In a ground-breaking report released in July 2021, the Axial Spondyloarthritis International Federation (ASIF) looks at key diagnosis challenges across different healthcare systems to better understand how the delays affect individuals and to identify opportunities for addressing these. ASIF’s Delay to Diagnosis Report is based on a full literature review, and two global forum events, involving more than 90 patients and patient group representatives, researchers, rheumatologists, and other healthcare professionals from 23 countries. The report identifies that an average 7-year delay to diagnosis of axial spondyloarthritis (axSpA) can leave young patients with irreversible damage to their spine and a devastating effect on their mental health.

Diagnosis of ankylosing spondylitis

Many people with AS have family members who also have the disease, so a family history of AS should be considered a risk factor. If a person is showing signs of the disease it is vital that their family physician and rheumatologist be made aware of any family history of AS.

Doctors may do blood tests to determine the presence of inflammation in the body, and to test for specific markers which indicate a genetic risk for AS. An x-ray may also be taken, but it is important to remember that often signs of AS may not be visible until the disease has progressed to a point where joint damage has already occurred. This is why the site of the stiffness, characteristics of onset of pain, and the time of day when pain is worst, may be the most important factors to analyze when diagnosing AS.

As is the case with most forms of inflammatory arthritis, early diagnosis and treatment of AS can be key factors in maintaining joint health and preventing disability and deformity; if the inflammation associated with AS continues unchecked, changes to the spinal column are likely to result, causing spinal immobility and limitation of range of movement. If AS affects the hips, damage can result in the need for total hip replacement surgery.

Treatment of ankylosing spondylitis

If your doctor believes you may have ankylosing spondylitis, you will usually be referred to a rheumatologist-a specialist in the treatment of arthritis. Rheumatologists have many years of extra training on top of their regular medical schooling, and are experts at diagnosing and treating all forms of arthritis, including ankylosing spondylitis.

Once your rheumatologist has diagnosed ankylosing spondylitis, there are effective treatments available to help you manage the symptoms and minimize joint damage. While there is no known cure for ankylosing spondylitis, treatments are available, and your rheumatologist is the best person to discuss these with and formulate a treatment plan to address all aspects of ankylosing spondylitis.

Recently, treatment guidelines were established for the management of this disease. These include several groups of medications such as:
  • Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil® or Motrin IB®), naproxen (Naprosyn®), diclofenac (Voltaren®)
  • COX-2 inhibitors, such as celecoxib (Celebrex®)
  • Glucocorticoid (sometimes called 'cortisone') injections directly to the site of inflammation. Unlike other forms of arthritis, there is little evidence to support the use of glucocorticoid tablets such as prednisone or other "systemic corticosteroids" for disease involvement in the spine.
  • There is little evidence to support the use of traditional disease-modifying anti-rheumatic drugs (DMARDs) used in treating rheumatoid arthritis such as methotrexate, sulfasalazine, hydroxychloroquine, leflunomide and azathioprine for the treatment of spinal disease involvement. However, sulfasalazine may be used in patients with ankylosing spondylitis with peripheral (large joints such as elbows, wrists, knees, and ankles) disease involvement.
  • Biologic DMARDS (or "biologics"), specifically adalimumab (Humira®), etanercept (Enbrel®) and infliximab (Remicade ®), have all been approved in Canada for use in treating ankylosing spondylitis - both the spinal inflammation and the peripheral inflammation.

These medications can work alone or frequently in combination to reduce the pain and other symptoms associated with ankylosing spondylitis.

In addition to pharmacological medications, treatment guidelines for ankylosing spondylitis also include essential non-pharmacological approaches. In particular, a treatment plan for this disease should also include patient education as well as exercise and physical therapy to maintain a range of motion, flexibility, and good posture. Smoking cessation, maintaining a healthy diet and weight are an important part of managing ankylosing spondylitis, as well as other types of arthritis.