By Anca Askanase, MD, as told to Hallie Levine
Ankylosing spondylitis can be a devastating disease. But the good news is that the future is brighter than ever before. HereтАЩs why IтАЩm so optimistic.
We Have Better Diagnosis Tools
Doctors — including primary care physicians — are now more educated about ankylosing spondylitis. So patients are getting diagnosed earlier, which improves their prognosis. Oftentimes, patients in the initial stages of disease wonтАЩt have any signs of inflammation of the sacroiliac joints — the joints that connect the spine to the pelvic bone — on an X-ray.
But doctors can now test for the human leukocyte antigen (HLA) gene, HLA-B27, and do MRIs of the area to see if thereтАЩs inflammation. In the past, by the time we made a diagnosis and embarked on whatever minimal treatment options we had, the damage was already done. We were chasing the disease and trying to clean up its effects, as opposed to being ahead of it and attempting to stop it in its tracks.
Treatments Have Advanced
Biologics have revolutionized treatment of ankylosing spondylitis over the past 2 decades. These drugs slow certain cytokines, which are molecules that signal your cells to activate inflammation throughout your body. Cytokines play an important role in preventing disease, but when theyтАЩre overactivated, they can trigger inflammatory disease such as ankylosing spondylitis.
WeтАЩve made an enormous difference in changing the face of this disease with these extraordinary tools at our finger tips. WeтАЩve gone from barely scratching the surface of ankylosing spondylitis to people being able to achieve complete symptom relief and live normal lives. ThereтАЩs still a lot of work that needs to be done, but itтАЩs so wonderful for me to be able to tell patients that theyтАЩre in remission. Medications currently available include:
Anti-tumor necrosis factor therapy (TNF inhibitors). These were the first biologics to be approved for ankylosing spondylitis in 2003. They treat not only joint arthritis, but gut and eye inflammation, as well as spinal arthritis. They do lower your immunity, so youтАЩre at increased risk of infection, including tuberculosis (a TB test is required before starting). But many of my patients see amazing results. If they donтАЩt respond to one, they often will to another. There are currently five FDA-approved for ankylosing spondylitis: Enbrel, Humira, Remicade, Simponi, and Cimzia.
Anti-interleukin 17 therapy (IL-17 inhibitors). This is another class of biologic medications. There are currently two approved by the FDA: secukinumab (Cosentyx) and ixekizumab (Taltz). Since IL-17 inhibitors target different cytokines than the TNF inhibitors, theyтАЩre a good option for patients who donтАЩt respond to TNF inhibitors or arenтАЩt able to tolerate them.
There Are Promising Treatments in the Pipeline
While biologics are very successful, they donтАЩt work for everyone. ThatтАЩs why IтАЩm so excited about Janus kinase (JAK) inhibitors, medications traditionally used to treat rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis. They inhibit several cytokines key to the progression of ankylosing spondylitis. While there are three currently available in the United States — tofacitinib (Xeljanz), baricitinib (Olumiant), and upadacitinib (Rinvoq) — none have been approved to treat ankylosing spondylitis. But that may soon change. A 2021 study published in the Annals of the Rheumatic Diseases found that tofacitinib (Xeljanz) significantly improved symptoms such as fatigue, inflammation, and back pain in patients with ankylosing spondylitis compared to those who took a placebo. Even better, JAK inhibitors are more convenient for people than biologics, since you can take them orally. Biologics have to be taken via an at-home injection or an IV in your doctorтАЩs office.
Today, when I see people with ankylosing spondylitis, I stress to them that in just a matter of 2 decades, treatment — and prognosis — has changed dramatically. People are able to work, have families, and continue doing their favorite sports and activities. Things that would have seemed unthinkable even just 15 years ago.
ThereтАЩs still no cure for ankylosing spondylitis, and there may never be one. But at least now, people with the condition can lead long, productive lives. IтАЩm very hopeful that as we push our understanding of the disease and gain a better understanding of where it comes from, weтАЩll make progress in therapies.
In the meantime, I help guide people to their best treatments, encourage them to exercise and participate in physical therapy, and suggest they eat an anti-inflammatory diet rich in healthy foods such as fruits, vegetables, and fatty fish. If they do all this, thereтАЩs a good chance they can control the course of their disease, rather than having their ankylosing spondylitis control them.
