Ankylosing spondylitis

Definition

Ankylosing spondylitis (AS) is an autoimmune disease, that is, the body’s defense system (immune system) does not work properly and attacks its own cells. AS is a type of arthritis that mainly affects the joints in the spine. This results in spinal inflammation.

The adjective ankylosing means a fusion between the bones.

In some cases, AS can affect joints other than those in the spine, such as the shoulders, knees or hips.

AS affects the hips and shoulders in about 20% of patients.

AS is progressive, that is, the disease evolves over time with active phases of the disease (relapses) and inactive phases (remission).

This is a chronic disease.

Epidemiology

The disease affects more men than women, it is estimated that men are 2 times more affected by the disease than women. It usually starts before age 45. Only 5% of those diagnosed are over 45 years of age. In general, the disease begins between 20 and 39 years.

In the United States, about 1 in 200 adults have ankylosing spondylitis. In 2017, that represented approximately 1 million adult Americans. These numbers come from the   Spondylitis Association of America .

Causes

The causes of the disease are still not fully known.
Genetic influence
However, it is assumed that the presence of certain genes, such as the so-called HLA-B27, may favor the development of AS (see also below under Diagnosis ), because more than 80% of people with AS carry this gene. But having that gene or marker doesn’t necessarily mean that the person will develop AS. In fact, 6% of Americans carry this gene and most will never develop AS.1 . Other genes may play a role in the development of the disease.

Other influences
Different factors, mainly of infectious origin or a dysfunction of the immune system, can favor the development of the disease. Smoking is a risk factor for AS.

Groups of risk

Young men under 45 years of age are the main risk group.

Symptoms

Ankylosing spondylitis manifests itself mainly through the following symptoms:
– Pain and stiffness in the lower back and hips. These symptoms tend to improve with physical activity. The pains can cause night awakenings. The patient often feels a stiffness in the back upon awakening.
– Fatigue  (caused mainly by the inflammatory signs of the disease)
– Chest pain and difficulty breathing due to tightness in the chest.

AS can appear as relapses, followed by remission phases (phase in which symptoms disappear).
The disease can lead to ossification in the spine due to the fusion of ligaments as well as bone erosion.

Duration of symptoms
The duration of back pain is often longer than 3 months.

Note on symptoms 
Symptoms can be very different from one person to another. Women, in particular, often have more atypical symptoms than men.

Diagnosis

Diagnosis is a matter for the physician alone. In general, it is the rheumatologist who treats this disease.
Different diagnostic methods can be used, such as medical imaging techniques (for example, X-rays of the spine), anamnesis , blood tests to look for the HLA-B27 gene (see Causes above).

Diagnosis is often difficult and it can take years (average 5 to 14 years) before AS is clearly identified by a medical team2.

Some tools also allow assessing the disease and especially its development, they are the Bath Ankylosing Spondylitis Disease Activity Index -BASDAI (in Portuguese: Bath Activity Index for Ankylosing Spondylitis) and the Bath Ankylosing Spondylitis Functional Index – BASFI ( in Portuguese : Bath Functional Index for Ankylosing Spondylitis). Methods based on various questions to ask the patient.

Complications

Ankylosing spondylitis can lead to complications such as:

– Eye disorders (acute inflammation of the eye or uveitis). This complication occurs in approximately 30% of patients with the disease. Symptoms include: redness, pain, eye sensitivity, watery eyes, blurred vision.

– Digestive disorders (eg Crohn’s disease , ulcerative colitis) These disorders occur in approximately 10 to 15% of patients.

– Osteoporosis . Doctors often do not consider osteoporosis because the patients are often young men. It is known that osteoporosis is a more prevalent disease in postmenopausal women. AS appears to change bone structure.

– Fractures.

– Kidney disorders.

– Cardiovascular diseases.

– Skin problems, including psoriasis .

Bone fusion
In severe cases, the inflammatory process of ankylosing spondylitis can lead to a fusion (or “ankylosis”) of the bones of the spine and sometimes other joints. This melting process usually occurs years after the onset of the disease. These bony fusions increase the risk of fractures and decrease mobility.

Treatments

There are several treatments for ankylosing spondylitis.

Medicines :

– NSAIDs and corticosteroids

NSAIDs (nonsteroidal anti – inflammatory drugs, NSAIDs) such as ibuprofen and coxibs such as celecoxib can be used against the pain and inflammation caused by AS, particularly early in the disease. They are first-line drugs, preferably used as a first treatment. The medical team can also use corticosteroids when there is an insufficient response to NSAIDs and coxibs, although biologics are increasingly the treatment of choice in this case.3 (read below).

– Medicines that act on the disease

In English we talk about DMARDs – disease-modifying antirheumatic drugs . These drugs have the ability to modify the disease and act on the immune system. In this family of drugs we find, for example, methotrexate. DMARDs are mostly used in peripheral disorders.

The biological ones . These are treatments with anti-inflammatory properties that have, as the name suggests, a biological-type chemical structure similar to a protein. These biologics have the ability to act directly on the immune system and modify certain biochemical functions, such as the inflammatory process. They act mainly against the tumor necrosis factor, called TNFα or TNF-alpha, and against interleukin 17A. Biologics are often first-choice treatments when NSAIDs and coxibs do not work as expected.
– Among the anti-TNF-alpha agents we can mention the monoclonal antibodies: infliximab, adalimumab (eg Humira®), etanercept (eg Embrel®), certolizumab or golimumab
Monoclonal antibodies are of proteins that recognize and bind to other specific proteins, as in this case binding to TNF-alpha.
– Interleukin 17A (IL-17A) inhibitors include: secukinumab (Cosentyx®), ixekizumab (Taltz®). These drugs work by neutralizing interleukin 17A activity, which is elevated in conditions such as AS and other rheumatic diseases.
– There are also Janus Associated Kinases (i-JAK) inhibitors that can be used against AS, such as upadacitinib (eg Rinvoq®). The effectiveness of upadacitinib is based on limiting Janus Kinase activity in the body, limiting inflammation.

Note: These drug treatments are usually taken for life.

– Physical treatment Physical
therapy can help treat the disease, mainly to reduce pain. Also read below under Tips .

– Surgery
In some cases, surgery may be required. As noted by the American Spondylitis Association of America , surgery is a rarely used therapy to combat this disease. Surgery is particularly used when the disease affects the knees or hips.

Tips

– Avoid smoking. Ankylosing spondylitis can lead to the development of hard tissue in the chest and lungs. This leads to additional difficulty in breathing in patients who smoke.

Importance of sleep: 
– Sleep in general can contribute to recovery. Make sure you are well rested and in a comfortable position, this can help your muscles relax. If possible, avoid sleeping on your stomach (belly down), as this can put undue stress on your lower back. If you are a back sleeper, use a neck support pillow designed for back sleepers. You can also place a pillow under your legs to help keep your back straight. If you sleep on your side, opt for a slightly higher pillow. Also use a pillow between your legs. Some experts also advise against sleeping with a pillow for patients with AS.

– Control your weight. Overweight and obesity in particular can increase stress on joints. Furthermore, adopting a Mediterranean-type diet has been shown to reduce inflammation in rheumatic diseases such as AS, not to mention that this diet can help maintain a proper weight.

– Exercise regularly, it strengthens your muscles and spine. Ask your doctor about which exercises to practice.

– Practice good posture. It is important to stand upright when you walk or sit.

– Reduce stress. A good way to alleviate the symptoms of the disease.

– Take a hot shower. Heat can help relieve pain and stiffness. Therefore, do not neglect the benefits of a hot shower.

– As AS can cause ankle pain, it is important that you find shoes that support it. Look for ones that offer a padded base and support close to the ankle.4.

Jeanne Kenney
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I’m a stylist trainer, a content creator, and an entrepreneur passion. Virgo sign and Pisces ascendant, I move easily between my dreams, the crazy world I want, and my feet on the ground to carry out my projects.

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