Your doctor may prescribe certain treatments, such as nonsteroidal anti-inflammatory drugs and physical therapy, to help with ankylosing spondylitis. But everyone is different: what works for someone else may not work for you. If this happens, your doctor will likely recommend trying a new class of drugs known as biologics.
“These are amazing drugs that have revolutionized the way we treat this disease,” says Deborah Desire, MD, a rheumatologist at Yale Medicine.
Although it won’t magically cure ankylosing spondylitis, it can help slow the progression of the disease and make symptoms more manageable.
How does biology work?
Biologic medicines stop the harmful inflammation that occurs with ankylosing spondylitis.
“They are genetically modified proteins that target cytokines, which are certain molecules in your immune system,” says Leanne Gensler, MD, director of the ankylosing spondylitis clinic at the University of California, San Francisco.
Cytokines activate inflammation throughout the body, keeping your immune system on its toes to fight off invaders. But if the speed is increased, it can lead to inflammatory diseases such as ankylosing spondylitis.
There are two main classes of biopharmaceuticals used to treat ankylosing spondylitis:
Tumor necrosis factor-alpha (TNF-α) inhibitors. This was first approved in 2003. These medications not only relieve arthritis, but also reduce inflammation associated with the intestines and eyes. There are five approved treatments for ankylosing spondylitis:
- adalimumab (Humira)
- certolizumab (Simzia)
- Entanercept (Enbrel)
- golimumab (Simponi)
- infliximab (Remicade)
IL-17 inhibitors. Two are FDA-approved for the treatment of ankylosing spondylitis: exekizumab (Taltz) and secukinumab (Cosentyx). They target cytokines different from TNF inhibitors. They are often used in people whose ankylosing spondylitis has not responded to many TNF medications.
Who Should Take Biology?
While biologics are very effective, they are not for everyone.
“These medications are very powerful, but they also suppress the immune system, which means you are more likely to get infections,” Gensler says. For this reason, most doctors refrain from using them immediately.
When you’ve recently been diagnosed with ankylosing spondylitis, your doctor will likely start you with a course of non-steroidal anti-inflammatory drugs (NSAIDS). These include over-the-counter versions such as ibuprofen, as well as stronger prescription medications such as celecoxib (Celebrex).
“These are the most common medications we use, and with good reason: A large percentage of patients can manage their symptoms on them,” Desir says.
They will also prescribe physical therapy to help ward off a “frozen” spine and general stiffness that can occur with ankylosing spondylitis.
The downside to NSAIDs is that most people need very high doses to stay symptom-free. Over time, this can lead to side effects such as stomach bleeding and an increased risk of heart attack or stroke.
We are very concerned about these side effects in the elderly, because they are already at risk for these diseases. But for a newly diagnosed younger patient in their 20s or 30s, this is less of a concern,” says Gensler. “We don’t have long-term safety data on biopharmaceuticals beyond two decades, so it’s still not It is known what effects these drugs have on patients who suffer from them throughout most of their lives. That’s why we prefer to start with NSAIDs, and then escalate if necessary.”
In general, Gensler says you should consider probiotics if:
- I’ve tried a course of NSAIDs and physical therapy for a few weeks and I’m still bothered by the symptoms.
- X-rays actually show that you have a lot of damage to the sacroiliac joints, which are the joints that connect the spine to the pelvic bone.
- I have actually lived with ankylosing spondylitis for a long time.
It can sometimes take up to 10 years for people to be diagnosed with this condition.
“Patients sometimes come in for the first visit in so much pain and so disabled, they say their quality of life is poor and they would do anything to get her back to where they can work again,” Gensler says.
What should I expect when I take the biological preparation?
If you and your doctor agree that biopharmaceuticals are the next step, they will test you for tuberculosis first.
“Some people have what’s known as latent tuberculosis, where the bacteria live silently in their lungs,” Desir says. “Because these drugs suppress your immune system, TB can ‘wake up’ and cause an actual infection.”
All biological treatments make you more susceptible to infections, especially upper respiratory infections such as the common cold, flu, or COVID-19. To stay healthy, you must:
- wash your hands often
- Avoid or wear a mask in crowded areas, enclosed spaces, public transportation and childcare facilities
- Stay up-to-date on all your vaccinations, including the flu and COVID-19 vaccinations.
Some biopharmaceuticals are given at home by self-injection, while others are given through an intravenous infusion in your doctor’s office. You may notice some pain, redness, and swelling. You can use antihistamines and over-the-counter pain relievers such as acetaminophen to treat the discomfort.
If you’re familiar with trying a biologic drug, Gensler suggests giving it a 3-month trial.
“I assure (people) that this doesn’t have to be a lifelong commitment. They can always get off the biologics and go back to their original medications,” she says. “But often, after a few months, people are shocked at how much better they feel. They have suffered for a long time and just accepted their symptoms as normal. But thanks to biology, it doesn’t have to be that way anymore.”
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