musculoskeletal and connective tissue disorders
Ankylosing Spondylitis
Treatment of Ankylosing Spondylitis
Nonsteroidal anti-inflammatory drugs (NSAIDs) Sulfasalazine,methotrexate, tumor necrosis factor (TNF)-alpha antagonists, or interleukin-17 (IL-17) antagonists (eg,secukinumab,ixekizumab) Exercises and supportive measures The goals of treatment of ankylosing spondylitis are relieving pain, maintaining joint range of motion, and preventing end-organ damage. Because the condition may cause lung fibrosis, cigarette smoking is discouraged. (See also2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.) Nonopioid Analgesics reduce pain and suppress joint inflammation and muscle spasm, thereby increasing range of motion, which facilitates exercise and prevents contractures. Most NSAIDs work in ankylosing spondylitis, and tolerance and toxicity dictate drug choice. The daily dose of NSAIDs should be as low as possible, but maximum doses may be needed with active disease. Drug withdrawal should be attempted only slowly, after systemic and joint signs of active disease have been suppressed for several months. Sulfasalazinemay help reduce peripheral joint symptoms and laboratory markers of inflammation in some patients. Dosage should be started at 500 mg/day and increased by 500 mg/day at 1-week intervals to 1 to 1.5 g 2 times a day maintenance; because acute neutropenia can occur, cell counts must be monitored when initiating therapy or increasing drug dose. Peripheral joint symptoms may also abate withmethotrexate, but spinal symptoms are usually not reduced. Clinical studies have provided inconsistent results regarding efficacy of these medications. TNF-alpha antagonists (eg,etanercept,infliximab,adalimumab, certolizumab,golimumab) are often strikingly effective treatments for inflammatory back pain.Adalimumaborinfliximabare preferred overetanerceptfor the treatment of ankylosing spondylitis in patients with recurrent uveitis. For patients who fail TNF-alpha antagonists, switching to an IL-17 antagonist is preferred to switching to another TNF-alpha antagonist. Secukinumab, an IL-17 antagonist, has also been effective in reducing inflammation and joint symptoms.Secukinumabcan be given at a dosage of 150 mg subcutaneously at weeks 0, 1, 2, 3, and 4 and every 4 weeks thereafter. Without the loading (weekly) doses,secukinumabis 150 mg subcutaneously every 4 weeks. Adverse effects include urticaria, upper respiratory infections, fungal infections due toCandida, diarrhea, herpes zoster, and worsening symptoms of inflammatory bowel disease. Ixekizumab, another IL-17 inhibitor, can be given for active ankylosing spondylitis as an injection of 80 mg/mL for adult patients every 4 weeks after a loading dose of 160 mg (two 80-mg injections) at week 0, followed by 80 mg at weeks 2, 4, 6, 8, 10, and 12. It can be administered as monotherapy or in combination with conventional DMARDs or NSAIDs. Discontinuation of biologics is not recommended due to the likelihood for symptom recurrence. Systemic corticosteroids, immunosuppressants, and most disease-modifying antirheumatic drugs (DMARDs) have no proven benefit in axial spondyloarthritides and should generally not be used. For proper posture and joint motion, daily exercise and other supportive measures (eg, postural training, therapeutic exercise) are vital to strengthen muscle groups that oppose the direction of potential deformities (ie, the extensor rather than flexor muscles). Reading while lying prone and pushing up on the elbows or pillows and thus extending the back may help keep the back flexible. Because chest wall motion can be restricted, which impairs lung function, cigarette smoking, which also impairs lung function, is strongly discouraged. Intra-articular depot corticosteroids may be beneficial, particularly when one or two peripheral joints are more severely inflamed than others, thereby compromising exercise and rehabilitation. They may also help if systemic drugs are ineffective. Imaging-guided corticosteroid injections into the sacroiliac joints may occasionally help severe sacroiliitis. For Overview of Uveitis , topical corticosteroids and mydriatics are usually adequate. If severe hip arthritis develops, total hip arthroplasty may lessen pain and improve flexibility dramatically. 