Ankylosing spondylitis: Understand your treatment options

Although there's no cure for ankylosing spondylitis — a type of arthritis that affects the spine — treatment can ease your symptoms and possibly slow the progression of the disease.

Ankylosing spondylitis usually starts with pain and stiffness in the back, after times of inactivity. Symptoms typically develop gradually, before age 45, and last more than three months. Pain and stiffness tend to ease with activity but may become ongoing and spread to the neck, ribs, shoulders and heels. When the problem is severe, bones in the spine can fuse together. This can make those parts inflexible, which may stiffen the ribs — making it hard to breathe deeply — or cause a hunched posture.

Ankylosing spondylitis treatment is most successful when started before the disease causes irreversible damage to your joints. Before meeting with your health care provider, it may help to understand the treatment options.

Ankylosing spondylitis treatment usually starts with physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs).

• Physical therapy. A physical therapist designs specific exercises for your needs. These exercises can help improve strength. Range-of-motion and stretching exercises can help keep your joints flexible and preserve good posture. Proper sleep and walking positions and abdominal and back exercises can help maintain your upright posture too.
• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve swelling, pain and stiffness. NSAIDs available without a prescription include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Prescription NSAIDs approved by the Food and Drug Administration (FDA) for treating ankylosing spondylitis include naproxen (Naprosyn), sulindac, diclofenac, indomethacin (Indocin), and piroxicam (Feldene). Often, these may be the only medications needed. A potential side effect, however, is bleeding in the stomach or intestines.

If NSAIDs aren't helpful, your health care provider might suggest a biologic medication. These could include:

• Tumor necrosis factor (TNF) blockers. TNF blockers help reduce pain, stiffness, and tender or swollen joints. The drug is given as an injection under your skin or in a vein. This is called an intravenous injection. The five TNF blockers approved by the FDA to treat ankylosing spondylitis are adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi) and infliximab (Remicade).
• Interleukin-17 (IL-17) inhibitors. An IL-17 inhibitor also may help ease inflammation and is given as an injection under your skin. Secukinumab (Cosentyx) and ixekizumab (Taltz) are approved by the FDA for the treatment of ankylosing spondylitis.

Potential side effects of TNF blockers and IL-17 inhibitors are reactivation of inactive tuberculosis and an increased risk of infections.

If treatment with TNF blockers or IL-17 inhibitors isn't effective, another option is a Janus kinase (JAK) inhibitor. JAK inhibitors are taken by mouth. Upadacitinib (Rinvoq) and tofacitinib (Xeljanz) are approved by the FDA for the treatment of ankylosing spondylitis. These types of medicines can reactivate untreated tuberculosis and make you more prone to infections. These medicines also increase the risk of developing shingles, also called herpes zoster. Your rheumatologist may recommend that you get vaccinated against shingles. This class of medications also has a warning about higher risks of heart attacks, strokes, blood clots and cancer, especially in individuals older than 50 years.

Most people with ankylosing spondylitis don't need surgery. But if you have severe pain or joint damage, or if your hip joint is so damaged that it needs to be replaced, your health care provider might recommend surgery.

Regardless of what treatments you and your health care team choose, it's important to see your health care provider often and follow your treatment plan. This can help you avoid complications and worsening symptoms and keep your joints working as well as they can.