eMedicine Specialties > Neurology > Inflammatory and Demyelinating Diseases
Ankylosing Spondylitis: Treatment & Medication
Updated: Jan 8, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
General principles of management include the following:
- Exercise and postural training
- Medications to decrease pain and inflammation, tumor necrosis factor-alpha antagonists are valuable recent additions to the medication options. When used, they rapidly reduce symptoms and slow disease progression.
- Diagnosis and treatment of potential complications
Surgical Care
Surgical treatment may be necessary for some complications of ankylosing spondylitis.
- Surgical fusion may be required for stabilizing atlantoaxial subluxation.
- Cervical spine fractures require rigid immobilization, usually with a halo. In the past, surgical fusion was usually not performed. With neurological deficit, early surgical intervention with fusion is often recommended. Neurological deficit often improves after surgery.
- Surgery rarely is indicated for correction of uncomplicated thoracic kyphosis. If functional impairments are present, correction of the spinal deformity may be necessary; however, postoperative mortality from various complications is substantial, 4%.
- Thoracolumbar fractures require reduction of displacement and stabilization, usually with rods. Laminectomy rarely is needed.
- Decompression of cervical or lumbar spinal stenosis is indicated when neurological structures are involved.
- If weight-bearing joints are involved, hip or knee replacement may be necessary. The most common surgical procedure in these patients is a total hip arthroplasty.
Consultations
- If patients have complaints of eye pain, visual changes, or increased lacrimation, an ophthalmologist should be consulted to evaluate and treat for iritis or uveitis and rule out other causes of these conditions.
- Chest pain may require evaluation by a cardiologist or pulmonologist. Aortic regurgitation, sometimes associated with heart block, may need further treatment. Because apical pulmonary fibrosis may allow for opportunistic infection, pulmonary care may be necessary.
- Consultation with an orthopedist or neurosurgeon is indicated when spinal trauma occurs or in the setting of persistent pain or neurological deficit.
- Orthopedic care may be needed if weightbearing or shoulder joints are involved. Plantar fasciitis may require orthopedic or podiatry consultation.
- If associated inflammatory bowel disease is present, evaluation and treatment by a gastroenterologist may be necessary.
Activity
- Daily bending, twisting, and gentle range of motion exercises help prevent postural deformities and restriction of joint range of motion.
- Breathing exercises are recommended to prevent chest wall immobility.
- Encourage good sleeping posture with a small pillow on a firm mattress in either the supine or prone position.
Medication
The goal of pharmacotherapy is to control pain and decrease inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used medications. Sulfasalazine has been shown to be effective for peripheral joint involvement. Steroids and immunosuppressive agents are used sometimes. Injections of local steroids may offer symptomatic relief for local inflammation.
Nonsteroidal anti-inflammatory drugs
These agents reduce pain and inflammation. No particular NSAID has been shown to be clearly superior for treating ankylosing spondylitis.
Ibuprofen (Motrin, Advil, Haltran, Nuprin)
Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, thus inhibiting prostaglandin synthesis.
Adult
200-800 mg PO q6-8h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 30-70 mg/kg/d PO divided tid/qid; start at lower end of range and titrate upward; not to exceed 2.4 g/d
>12 years: Administer as in adults
Probenecid may increase concentrations and possibly toxicity; may decrease effects of loop diuretics; may increase serum lithium levels and risks of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Coadministration with anticoagulants may prolong prothrombin time (PT); consider effects that NSAIDs have on platelet function and gastric mucosa; Monitor PT and patients closely, and instruct patients to watch for signs and symptoms of bleeding
Documented hypersensitivity; because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients in whom aspirin, iodides, or other NSAIDs have induced symptoms of asthma, rhinitis, urticaria, nasal polyps, angioedema, bronchospasm, or other symptoms of allergic or anaphylactoid reactions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion are at greatest risk of acute renal failure
Low WBC counts are rare and transient; they usually return to normal as therapy continues; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuing drug
Perform ophthalmological studies in patients who develop eye complaints during therapy; effects include blurred or diminished vision, scotomata, changes in color vision, corneal deposits, and retinal disturbances (including maculae); discontinue therapy if ocular changes are noted; blurred vision may be significant and warrants thorough examination, including central visual fields and color vision testing; these changes may be asymptomatic, and thus periodic eye examinations should be performed in patients on prolonged therapy
Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
Relieves mild to moderately severe pain and inhibits inflammatory reactions, probably by decreasing activity of enzyme cyclooxygenase, thus inhibiting prostaglandin synthesis.
Adult
250-500 mg PO bid; may increase to 1.5 g/d for limited periods; generally, not to exceed 1.25 g/d
Pediatric
<2 years: Not established
> 2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Probenecid may increase concentrations and possibly toxicity; may decrease effects of loop diuretics; may increase serum lithium levels and risks of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Coadministration with anticoagulants may prolong prothrombin time (PT); consider effects that NSAIDs have on platelet function and gastric mucosa; Monitor PT and patients closely, and instruct patients to watch for signs and symptoms of bleeding
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion are at greatest risk of acute renal failure
Low WBC counts are rare and transient; they usually return to normal as therapy continues; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuing drug
Perform ophthalmological studies in patients who develop eye complaints during therapy; effects include blurred or diminished vision, scotomata, changes in color vision, corneal deposits, and retinal disturbances (including maculae); discontinue therapy if ocular changes are noted; blurred vision may be significant and warrants thorough examination, including central visual fields and color vision testing; these changes may be asymptomatic, and thus periodic eye examinations should be performed in patients on prolonged therapy
Diclofenac (Voltaren)
Has analgesic, antipyretic, and anti-inflammatory activity. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, thus inhabiting prostaglandin synthesis.
Doses above stated maximum generally do not increase effectiveness.
Adult
25 mg PO bid/tid; if well tolerated, increase daily dose by 25 or 50 mg at weekly intervals until satisfactory response obtained; not to exceed 150-200 mg/d
Pediatric
<14 years: Not established
>14 years: Administer as in adults
Probenecid may increase concentrations and possibly toxicity; may decrease effects of loop diuretics; may increase serum lithium levels and risks of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Coadministration with anticoagulants may prolong prothrombin time (PT); consider effects that NSAIDs have on platelet function and gastric mucosa; Monitor PT and patients closely, and instruct patients to watch for signs and symptoms of bleeding
Documented hypersensitivity
Because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients with hypersensitivity to aspirin, iodides, or other NSAIDs
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion are at greatest risk of acute renal failure
Low WBC counts are rare and transient; they usually return to normal as therapy continues; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuing drug
Perform ophthalmological studies in patients who develop eye complaints during therapy; effects include blurred or diminished vision, scotomata, changes in color vision, corneal deposits, and retinal disturbances (including maculae); discontinue therapy if ocular changes are noted; blurred vision may be significant and warrants thorough examination, including central visual fields and color vision testing; these changes may be asymptomatic, and thus periodic eye examinations should be performed in patients on prolonged therapy
Tumor necrosis factor antagonists
These agents inhibit the activity of cytokine TNF-alpha. Indications are a definitive diagnosis, active and refractory disease, with failure of conservative treatment. Treatment should be discontinued for patients who do not respond within after 6-12 weeks. Before use, refer to current practice guidelines for more complete discussions.
Infliximab (Remicade)
Chimeric IgG1k monoclonal antibody that neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Reduces infiltration of inflammatory cells and TNF-alpha production in inflamed areas. May be administered with or without methotrexate.
Adult
5 mg/kg IV infusion at 0, 2, and 6 wk as induction regimen, then 5 mg/kg q6wk for maintenance
IV infusion must be administered over at least 2 h; must use infusion set with in-line, sterile, nonpyrogenic, low-protein-binding filter (pore size <1.2 µm)
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
TNF-alpha modulates cellular immune responses; anti-TNF therapies, such as infliximab, may adversely affect normal immune responses and allow development of superinfections; more cases of lymphoma were observed in TNF-alpha blockers compared with controlled groups; may increase risk of reactivation of tuberculosis in patients with particular granulomatous infections
Etanercept (Enbrel)
Soluble p75 TNF receptor fusion protein (sTNFR-Ig). Inhibits TNF binding to cell surface receptors, thereby decreasing inflammatory and immune responses.
Adult
25 mg SC 2 times/wk
Pediatric
Not established
Do not administer within 3 mo of live virus vaccines (eg, MMR)
Documented hypersensitivity; sepsis
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Serious infections may develop and therapy should be discontinued if they occur; possible adverse effects include injection site pain, redness and swelling at injection site, and headaches; rare cases of lupuslike symptoms and heart failure have been reported (discontinue treatment if symptoms develop)
Adalimumab (Humira)
Recombinant human IgG1 monoclonal antibody specific for human TNF. Indicated to reduce signs and symptoms in patients with active AS. Can be used alone or in combination with methotrexate or other disease-modifying antirheumatic drugs (DMARDs).
Adult
40 mg SC q2wk
Pediatric
Not established
May interfere with immune response to live virus vaccine (MMR) and reduce efficacy; methotrexate decreases clearance (available data do not support adjusting dose of either adalimumab or methotrexate); coadministration with anakinra (an interleukin-1 antagonist that also blocks TNF) may cause additive adverse effects, particularly development of serious infections
Documented hypersensitivity; active infection
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Causes immunosuppression; may reactivate tuberculosis infection; increases risk for lymphoma development; associated with CNS demyelination (rare); discontinue if serious infection develops; autoantibody development may occur causing lupuslike syndrome; may cause hypersensitivity reactions, including anaphylaxis and hematologic adverse effects (ie, pancytopenia, aplastic anemia)
Antirheumatic agents
This agent relieves pain and joint swelling and treats GI lesions associated with inflammatory bowel disease.
Sulfasalazine (Azulfidine, EN-tabs)
Acts locally in colon to decrease inflammatory response; systemically inhibits prostaglandin synthesis.
Adult
Initial dose: 1 g PO tid/qid
Maintenance dose: 2 g/d PO divided tid/qid
Pediatric
<2 years: Not established
> 2 years:
Initial dose: 40-60 mg/kg/d PO q4-8h
Maintenance dose: 20-30 mg/kg/d PO divided qid
Decreases effects of iron, digoxin, and folic acid; increases effects of oral anticoagulants, methotrexate, and oral hypoglycemic agents
Documented hypersensitivity; hypersensitivity to sulfa drugs; GI or GU obstruction
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Use caution in patients with renal impairment, blood dyscrasias, impaired hepatic function, or urinary obstruction; possible adverse effects include headache, sore throat, anorexia, nausea, jaundice, reversible oligospermia, itching, skin rash, hives, hemolytic anemia, and cyanosis; Monitor CBC and microscopic urinalysis frequently
Corticosteroids
These agents relieve inflammation and joint pain associated with ankylosing spondylitis.
Prednisone (Deltasone, Orasone, Sterapred)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
May be given PO or injected into an inflamed joint, which may afford temporary relief from pain, stiffness, and swelling.
Adult
5-60 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve
Pediatric
4-5 mg/m2/d PO; alternatively, 1-2 mg/kg qd or divided bid/qid; taper over 2 wk as symptoms resolve
Clearance may be decreased by estrogens; when used with digoxin, may increase digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider increase in maintenance dose of prednisone); monitor patients for hypokalemia when taking with diuretics
Documented hypersensitivity; diabetes; mental illness; hypothyroidism; cirrhosis; viral, fungal, or tubercular skin lesions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Use caution in patients with hyperthyroidism, nonspecific ulcerative colitis, osteoporosis, peptic ulcer, and myasthenia gravis; abrupt withdrawal may cause adrenal crisis; possible adverse effects include hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections
Antimetabolites
These agents are second-line therapy to control symptoms of joint pain and inflammation in ankylosing spondylitis.
Methotrexate (Folex, Rheumatrex)
Mechanism of action in ankylosing spondylitis unknown; may affect immune function. Although clearly ameliorates symptoms of inflammation, no evidence that it induces remission.
Adult
7.5 mg/wk PO as a single weekly dose or 2.5 mg PO q12h for 3 doses given as a course once weekly; in either schedule, dosages may be adjusted gradually to achieve optimal response; not to exceed 20 mg total weekly dose ordinarily
Alternative: 0.2-0.4 mg/kg PO once weekly
Pediatric
5-15 mg/m2/wk PO/IM as single dose or as 3 divided doses given q12h
Concurrent NSAIDs may cause fatal interaction; oral aminoglycosides may decrease absorption and blood levels of PO methotrexate; charcoal lowers plasma levels of both PO and IV forms, which may be particularly significant with high-dose therapies; etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response to methotrexate; indomethacin and phenylbutazone can increase plasma levels (mechanism of action not known, but may involve inhibition of renal prostaglandin synthesis or competitive renal secretion); may decrease phenytoin serum concentrations; procarbazine many increase nephrotoxicity; may increase plasma levels of thiopurines
Probenecid, salicylates, and sulfonamides (including TMP-SMZ) may increase therapeutic and toxic effects; inhibition of renal tubular secretion, competition for common elimination pathway, or protein displacement may be causes; however, if protein displacement is mechanism, may involve displacement of highly bound metabolic 7-hydroxymethotrexate, since parent drug is only 50% bound
Documented hypersensitivity; alcoholism, alcoholic liver disease, or other chronic liver disease; laboratory evidence of immunodeficiency syndromes, preexisting blood dyscrasias such as bone marrow hypoplasia, leukopenia, thrombocytopenia, or significant anemia
Pregnancy
X - Contraindicated in pregnancy
Precautions
Monitor blood cell counts at least monthly; liver and renal functions, q1-3 mo during therapy; during initial or changing doses, or periods of increased risk of elevated methotrexate blood levels (eg, dehydration), more frequent monitoring may be indicated; stop methotrexate immediately if blood cell counts drop significantly; aspirin, NSAIDs, or low-dose steroids may be continued, although possibility of increased toxicity with concomitant NSAIDs (including salicylates) has not been fully explored
Potential adverse effects include hepatotoxicity, interstitial pneumonitis, bone marrow suppression, severe nephropathy, opportunistic infections, ulcerative stomatitis, and diarrhea
More on Ankylosing Spondylitis |
| Overview: Ankylosing Spondylitis |
| Differential Diagnoses & Workup: Ankylosing Spondylitis |
 Treatment & Medication: Ankylosing Spondylitis |
| Follow-up: Ankylosing Spondylitis |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
ankylosing spondylitis, Marie-Strümpell arthritis, Bechterew disease, spondyloarthritis, spondyloarthropathy, chronic inflammatory conditions, AS, inflammation of the joints, inflammation of the tendons, inflammation of the ligaments, iritis, uveitis, aortitis, pulmonary fibrosis, amyloidosis, inflammatory bowel disease
