Ankylosing spondylitis: (AS)

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Ankylosing spondylitis: (AS)

What is ankylosing spondylitis?

Ankylosing spondylitis is chronic, inflammatory arthritis that mostly involves the spine. The chronic inflammation in more advanced cases may cause fusing to the affected areas, which reduces mobility and causes pain- particularly in the back.

Who can develop ankylosing spondylitis?

Close to 3 million Americans have ankylosing spondylitis. This condition is more common in men than women and usually develops in late adolescence or early adulthood. It must be noted that this condition can occur at any time, so even children can be affected and is known as juvenile spondylitis.

Where does ankylosing spondylitis occur?

Ankylosing spondylitis is most commonly seen in the bones of the back called vertebrae; however, it can also occur in other body parts. Other common locations for ankylosing spondylitis include:

  • Ribs
  • Eyes
  • Pelvis
  • Back of the heel
  • Locations where ligaments or tendons insert into the bone
  • Hips
  • Shoulders
  • Hands
  • Feet
  • Lungs
  • Heart

Causes

What is the cause of ankylosing spondylitis?

Currently, there is no known cause for this condition. There has been some research that shows certain genes are more susceptible to developing ankylosing spondylitis. The gene HLA-B27 has shown to be greatly linked with ankylosing spondylitis, however, more research is needed to determine the exact correlation between this gene as not everyone with this gene will develop this disease.

What are the risk factors for ankylosing spondylitis?

The following risk factors place you more at risk of developing ankylosing spondylitis:

  • Sex- Men have been shown to develop ankylosing spondylitis more than women.
  • Genetics- There is some link between having the HLA-B27 gene and ankylosing spondylitis.
  • Age- Ankylosing spondylitis usually develops between the ages of 17-45.

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Symptoms

What are the symptoms of ankylosing spondylitis?

The typical symptoms for ankylosing spondylitis is pain and stiffness to the back, but the neck may also be involved. The hallmark location in the vertebrae where ankylosing spondylitis occurs is the sacroiliac joint. It is most commonly felt in the morning, evenings, or after periods of rest. Symptoms vary from person to person and will not look exactly the same for everyone. Other symptoms may include: 

  • Fatigue
  • Anemia
  • Inflammation of the eyes
  • Gastrointestinal diseases

If you want to learn if your back symptoms could be due to ankylosing spondylitis (AS), please visit the following website and take the inflammatory back pain questionnaire: https://spondylitis.org/about-spondylitis/could-i-have-spondylitis/ 

What complications are associated with ankylosing spondylitis?

Here are some complications associated with severe ankylosing spondylitis:

  • Fusion of bones- Fusion of bones is due to the body’s attempt to compensate and try to heal from chronic inflammation. Unfortunately, the new bone that is made causes the fusion of bones, reducing mobility. If the rib cage is fused, this can cause severe complications with shortness of breath.
  • Eye disease- Chronic inflammation from this condition may cause red, painful eyes that tear more, are sensitive to light, and blurred vision. If you have been diagnosed with iritis or uveitis by your eye doctor, this could be related to ankylosing spondylitis
  • Compression fractures- This usually occurs after many years of  ankylosing spondylitis, where the bones have become thin due to years of inflammation and immobility, causing compression fractures even with minimal to no trauma. When this occurs in the vertebrae, the spinal cord and other vital nerves may become damaged.
  • Heart complications-  Ankylosing spondylitis can cause inflammation of the aorta causing dysfunction to the heart’s valves. Fortunately this is a rare complication of AS

Diagnosis

How is ankylosing spondylitis diagnosed?

Ankylosing spondylitis is diagnosed by a licensed healthcare professional, usually a rheumatologist, after performing a full history and physical examination. The physical evaluation focuses on looking for signs of joint (synovitis) and tendon (enthesitis, dactylitis) inflammation and may also involve examining the range of motion to the affected areas.

Are there any diagnostic tests that can be performed to confirm ankylosing spondylitis?

Most diagnostic tests for ankylosing spondylitis involve imaging tests. There are no labs used for this condition other than testing for the gene HLA-B27 and confirming inflammation from C-reactive protein and erythrocyte sedimentation rates (ESR). Those inflammatory tests are, however, not specific to ankylosing spondylitis, as they can also be elevated from other causes like an infection or rarely blood cancers. Blood work checking for anemia may also be performed as this may also be seen and can be the cause of fatigue. Here are the various imagining options available: 

  • X-rays- used to evaluate joints and bones affected from ankylosing spondylitis
  • MRI- helpful when detecting ankylosing spondylitis early on during the disease process before the x-rays have become abnormal

Treatment

What are treatment options for ankylosing spondylitis?

There is no cure for ankylosing spondylitis, so treatment mostly revolves around the management of symptoms and slowing down the progression of the disease. This is important in order to reduce spinal deformity.

Here are the different types of medications currently available for ankylosing spondylitis: 

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)- helpful with treating pain, swelling, and inflammation. The most common ones used for ankylosing spondylitis are:
  1. indomethacin (Indocin)
  2. naproxen (Naprosyn)
  • Tumor necrosis factor (TNF) blocker- an intravenous (IV) or subcutaneous (SQ) injection biologic that helps reduce pain, especially with joints, and reduces stiffness. Also helpful with preventing further damage from this condition. Examples include:
  1. Adalimumab (Humira)
  2. Certolizumab pegol (Cimzia)
  3. Etanercept (Enbrel)
  4. Golimumab (Simponi)
  5. Infliximab (Remicade)
  • Interleukin-17 (IL-17) inhibitor- another biologic helpful with inflammation for ankylosing spondylitis. Here are some IL-17 inhibitor options:
  1. secukinumab (Cosentyx)
  2. ixekizumab (Taltz)
  • Janus kinase inhibitor- used as a last resort when NSAIDs and traditional biologics fail.
  1.  tofacitinib (Xeljanz)

Other treatment options include:

  • Physical therapy- helpful with improving range of motion related to stiffness from chronic inflammation and bone fusion.
  • Surgery- only used in severe cases where pain cannot be managed with traditional treatments.

Although ankylosing spondylitis is a chronic condition with no cure, TeleMed2U rheumatologists offer integrative, holistic treatment approaches as well, based upon a “S.E.N.S.E.” - ible approach: Stress management, Exercise, Nutrition, Sleep & positive social Engagements, which not only help you manage your arthritis symptoms with less medications, but often helps you to lose weight.

Early diagnosis and an integrative treatment approach (not only relying on medications) with a qualified health professional continues to be the best method of treatment. Our providers at TeleMed2U are always available to help better manage your ankylosing spondylitis symptoms.

For more information about ankylosing spondylitis (AS) and its related conditions, please visit the Spondylitis Association of America’s website at: https://spondylitis.org/about-spondylitis/ 

Information

Medically reviewed by:

Dr Roy Kedem, MD

Dr Zenon Andreou studied medicine at University College London, graduating in 2006. His postgraduate training was in hospitals in and around London and he trained for four years in Otolaryngology before completing his training in General practice

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