Most treatment plans for ankylosing spondylitis include medication to help reduce the pain and stiffness experienced by patients. Once the pain and stiffness are controlled, a daily exercise program can be adopted to increase movement and flexibility. Several classes of medications can provide relief, including:

  • Traditional pain management medications and steroid injections
  • Disease modifying anti-rheumatic medications (DMARDs)
  • Biologics and immuno-suppressants.

Traditional Pain Management Medications

Many patients in the early stages of ankylosing spondylitis and with less severe forms of this type of arthritis find pain relief with well-known pain medications.

    Over-the-counter (OTC) non-steroidal anti-inflammatories (NSAIDs)
    These drugs are the most commonly used medications to treat the joint pain and back pain associated with ankylosing spondylitis. The group includes:

    • Aspirin
    • Ibuprofen (such as Advil, Motrin, and Nuprin)
    • Naproxen (such as Aleve)
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    For many people, they reduce the pain and stiffness associated with ankylosing spondylitis. The main NSAIDs risks include gastritis, peptic ulcer disease, increase in blood pressure and possibly an increased risk of heart attack and stroke.

    Prescription drug therapies
    Increasing evidence suggests that the class of NSAIDs known as cyclooxygenase-2-specific inhibitors, or COX-2 inhibitors (e.g., Celebrex), may reduce the risk of stomach problems associated with NSAIDs, although each patient will need to weigh the unique benefits and risks of COX-2 inhibitors.

    Other anti-inflammatory medications prescribed for the disease include prescription-strength naproxen (such as brand names Anaprox, Naprelan or Naprosyn), Indomethacin (such as Indocin), tolmetin (such as Tolectin), and Sulindac (such as Clinoril). Prescription NSAIDs carry the same risks as OTC NSAIDs (discussed above).

    Oral steroids
    Oral steroids such as prednisone) are almost never used in treating ankylosing spondylitis. Steroid injections can be effective for acutely painful or swollen joints, such as the knee, but are almost never given in the spine joints.

    Corticosteroid injections
    Injections with cortisone may help to relieve enthesitis of the Achilles tendon or plantar fascia.

Ankylosing Spondylitis
Ankylosing Spondylitis. Enlarge

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Drugs called DMARDs, which are typically used to treat rheumatoid arthritis (RA) and include sulfasalazine and methotrexate, have been used with limited benefits in ankylosing spondylitis patients.

    Sulfasalazine
    This drug is primarily used to control the joint pain and joint swelling from arthritis of the small joints (e.g. for knees, not the spine). Side effects, however, can include headaches, abdominal bloating and nausea/vomiting. Rarely, patients can develop bone marrow suppression. Accordingly, it is important for doctors to regularly monitor the blood counts of any patients taking sulfasalazine.

    Methotrexate
    This drug can also be effective in controlling symptoms associated with severe ankylosing spondylitis. Side effects include bone marrow suppression, oral ulcers, nausea, gastritis, and liver toxicity. Like sulfasalazine, use of methotrexate requires frequent monitoring of the blood counts and liver profile.

Biologics

These newer drug therapies are in a class of drugs also referred to as TNFα (tumor-necrosis factor alpha) blockers. These drugs aim to reduce the amount of TNF (a protein in the body that triggers inflammation leading to the symptoms of ankylosing spondylitis) produced by the immune system of patients. Some have been shown to actually slow the progression of the ankylosing spondylitis. In addition, they appear to treat both the joint pain associated with ankylosing spondylitis, as well as the spinal arthritis itself.

The four FDA-approved biologic medications for ankylosing spondylitis are:

  1. Enbrel (Etanercept). The first biologic approved to reduce signs and symptoms of ankylosing spondylitis. Enbrel is given as a weekly subcutaneous (under the skin) injection and can be delivered by the patient or a caregiver.
  2. Remicade (Infliximab). Remicade is given as a 2-hour IV (Intravenous) infusion every 6 weeks by a rheumatologist.
  3. Humira (Adalimumab). Humira is a subcutaneous injection given twice a month.
  4. Simponi (Golimumab). Simponi is a subcutaneous, self-injected medication given once a month to treat active ankylosing spondylitis.

These four biologic medications are quite effective in reducing the inflammatory process, which leads to the pain, fatigue and other symptoms of ankylosing spondylitis. Symptoms from injections such as redness, swelling, itching, rash or bruising sometimes occur at the injection site and typically lasts no more than 3 to 5 days. Patients should contact their doctor if these reactions don't go away or worsen. Other, more serious, side effects have been reported with the biologics and must be discussed in detail with your treating physician.

As summarized here, there are several well-known and new medications available to ankylosing spondylitis patients. Patients should discuss the pros and cons of each with their doctor to determine if any of the medications identified here could be effective given their unique ankylosing spondylitis symptoms. All medications have side effects, and interaction among medications should be considered when developing a therapy plan.

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Written by Judith Frank, MD
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