New Developments for Ankylosing Spondylitis

By Kathryn Dao, MD as told to Kara Mayer Robinson 

In recent decades, major advancements have been made in our understanding of ankylosing spondylitis (AS). We now know how to diagnose it and how to manage it better.

 

Better Diagnosis

We can now diagnose AS earlier because of improved technologies. 

Sixty years ago, we diagnosed people based on their symptoms. They were considered to have AS based on a doctor’s exam of their spine and what they told their doctors. 

Over the years, we began to consider the role of genes, inflammation in organs other than the spine, and MRI changes not seen on X-rays. For example, we now know that people with inflammatory back pain who don’t have X-ray changes but do have MRI changes have non-radiographic axial spondyloarthritis. This is an early stage or less aggressive form of AS that should be treated similarly to AS. 

There’s also more awareness about women with AS. Women may have different symptoms and their symptoms might mimic fibromyalgia.

Better Drug Treatments

In the past, the mainstay of treatment was high, long-term doses of nonsteroidal anti-inflammatory drugs (NSAIDS) or aspirin along with physical therapy. This had limited success in preventing AS from progressing or controlling symptoms. 

Now better and more effective therapeutic options are available. With the introduction of biologics and small molecule inhibitors, patients have less pain, improved function, improved quality of life, and a chance for disease remission. 

Tumor necrosis factor (TNF) alpha inhibitors were the first biologics approved by the FDA for AS. We’ve used them for 20 years, but some patients don’t respond, have contraindications, or have side effects from this drug. 

Recently, interleukin-17 (IL-17) inhibitors and Janus kinase (JAK) inhibitors were added to the list of medications that are proven effective and safe. The IL-17 inhibitors secukinumab and ixekizumab were approved by the FDA 5 years ago. The JAK inhibitors tofacitinib and upadacitinib were approved in the last few months. 

These drugs work differently to target inflammation, and they can change how your immune system works. They’re proven to be safe, effective, and good options for people who otherwise couldn’t take TNF inhibitors. 

While there have been successes, there have also been failures. Researchers ran studies on IL12 and IL23 inhibitors, as these drugs are effective for psoriatic arthritis and psoriatic spondylitis. But when evaluated for patients with AS, they didn’t work. 

There are more IL-17 inhibitors and JAK inhibitors in development.

Better Guidelines

We now have newly updated guidelines that help us choose the best treatment strategy for people living with AS. 

In 2019, the American College of Rheumatology, the Spondylitis Association of America, and the Spondyloarthritis Research and Treatment Network published guidelines on how to treat and manage AS and non-radiographic axial spondyloarthritis (nr-axSpA). 

In 2022, the Assessment of SpondyloArthritis International Society/European Alliance of Associations for Rheumatology (ASAS-EULAR) updated their guidelines. 

These guidelines are based on studies that looked at different treatment strategies, like which medicines to start first and which ones may be best if patients have other medical conditions.  They also address non-drug management, like educating patients about AS and exercise. 

These guidelines have been helpful for doctors and for those living with AS in deciding their care.

An Emphasis on Exercise

While medications help with inflammation, exercise and a healthy lifestyle are important to maintain mobility, flexibility, and quality of life. 

Recently, there’s been a greater emphasis on the role of exercise in managing AS. Many studies have shown that when people with AS exercise regularly, they see improvement in pain, function, and quality of life. 

In 2021, the European Alliance of Associations for Rheumatology issued recommendations on self-care strategies. It includes things like goal setting, cognitive behavioral therapy, and problem-solving. These strategies empower patients to take a more proactive role in their health. 

Doctors now talk to people with AS about physical activity, diet, and mental health to help them stay productive at work and at home.

Advancements in Daily Living With AS

There have been several advances that allow people with AS to maintain their quality of life and be gainfully employed. 

• The medications we have now are better at controlling the inflammatory disease and keeping patients functional.
• Policy changes have made the workplace friendlier to people who have disabilities and arthritis.
• Since the start of the pandemic, the option to work from home has really helped patients, as some no longer have to take long commutes to get to their jobs.

New Focus on Drug Timing for Surgery

Experts have also recently evaluated the safety and role of surgery for patients with AS. 

Surgery is reserved for those with spinal fractures, spinal infection, or those with severe spinal deformities at risk for neurologic deterioration. 

Recent recommendations focus on optimizing the timing of when to stop taking biologics or JAK inhibitors for surgery and when to start them again. That’s because they may increase the risk for infection and delay wound healing, but if they’re stopped prematurely, the disease will flare and inflammation may complicate surgery results. 

Ideally, you should discuss with your rheumatologist medication management before you schedule an elective surgery.

What May Happen Next

I believe the most notable change in the care and management of people with AS has been understanding the disease pathology and having the therapeutics needed to address the underlying cause of inflammation rather than just masking inflammation. 

This is an exciting time for rheumatologists and people we serve. We have more options available to control the disease and allow people to get back to living. I’m looking forward to the additional therapeutics and novel research on ankylosing spondylitis that will come in the next decade.