What Are Your Treatment Options for Advanced Ankylosing Spondylitis?

The way ankylosing spondylitis (AS) progresses varies person to person. Some people never experience anything more than back pain and stiffness that comes and goes. Others will have more severe problems, such as hunched posture or problems with walking, and severe disease complications like eye inflammation and nerve problems.

Treatment is important regardless of the severity of AS. Fortunately, there are many different medication classes available to slow down the disease and its effects.  

Advanced AS is often treated with stronger medicines, including corticosteroids, conventional disease-modifying antirheumatic drugs (DMARDs), biologic drugs, and JAK inhibitors. AS treatment might also include surgery and treatment of disease complications. Keep reading to learn about the effects of advanced AS and your treatment options.

AS Staging

AS affects 1% percent of the American population. It seems to affect men two to three times more frequently than it does women.

It is a condition that slowly affects the spine—from the sacrum (lowest part of the spine) to the neck. Early on, changes to the spine might be harder to spot but they will become visible with time. Imaging, including magnetic resonance imaging (MRI), can help your healthcare provider determine how much of your spine has been affected.

If AS gets worse, it will affect other body parts. This includes the entheses, the areas where tendons and ligaments attach to bone. As a result, you may experience pain in your ribs, shoulders, hips, thighs, or heels.

Treatment for early, mild AS starts with nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation. But if NSAIDs don’t provide relief, your healthcare provider may suggest stronger treatments.

What Advanced AS Looks Like

If AS has advanced and becomes severe, your healthcare provider might find that you have a fusion of the spine. This means there has been new bone growth between your vertebrae, causing the bones of the vertebrae to join together. The vertebrae are the small bones that make up the spinal column.

The more fusion there is in the spine, the less movement a person will experience in the spine. This is a slow process, and, while rare, might lead to complete fusion of the spine over time. Spinal fusion might increase your risk for fractures. It can also push the spine forward, which, over time, can cause the posture to hunch over.

Spine changes from AS can lead to problems with balance and mobility. They might also affect breathing due to upper body curvature towards the chest wall. Severe AS can also lead to pulmonary fibrosis (lung scarring), which increases the risk for lung infections.

Advanced AS might also cause eye inflammation that needs to be addressed to prevent vision loss. AS can also cause inflammation of the digestive tract. Up to 10% of people with advanced disease will develop inflammatory bowel disease (IBD).

Additional symptoms of advanced AS include:

• Vision changes or glaucoma
• Chest heaviness or discomfort from chest stiffening
• Reduced heart function: Call your healthcare provider right away if you experience chest pain or heaviness, or problems with breathing
• Severe back and joint pain

Treatment Goals in Advanced AS

Treatment for AS focuses on relieving pain and stiffness, reducing inflammation, keeping the condition from progressing, and helping you to keep up with daily activities. Treatment usually includes first-line and second-line therapies, and, as a last resort, surgery.

First-Line Therapies

First-line treatment for AS includes:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): These relieve pain and stiffness and reduce inflammation.
• Physical therapy: Physical therapy can help maintain your posture. Flexibility and stretching exercises will help you manage pain and stay mobile. Your physical therapist might also recommend deep breathing exercises if you experience chest pain and stiffness or lung involvement. 
• Assistive devices: Devices like canes and walkers can help you stay mobile, protect you from falls, improve your balance, and reduce stress on your joints.

Advanced Treatment

If first-line treatments do not help reduce pain and inflammation, or if your AS becomes severe, your healthcare provider might recommend advanced treatments. This might include corticosteroids, DMARDs, biologics, JAK inhibitors, or surgery.

Corticosteroids

Corticosteroids are human-made drugs that resemble cortisol, a hormone that naturally occurs in the body and is involved in a wide range of processes, including metabolism and immune system responses.

Corticosteroid drugs lower inflammation in the body. They can also reduce the effects of an overactive immune system. Your healthcare provider might prescribe a corticosteroid drug to relieve swelling and pain associated with AS.

If you experience a flare-up (a period of high disease activity) with AS, your healthcare provider may give you a corticosteroid injection in an affected area of your body. These injections can give you short-term relief from pain and swelling.

Injections can be given directly into a joint, including the sacroiliac joint (the area where your low back meets your pelvis), knee, or hip joint. Corticosteroids can help manage flares, but they are not considered the main treatment for AS.

Corticosteroids are available as oral medicines. Research shows the oral corticosteroid prednisolone at 50 milligrams (mg) per day can offer a short-term response to AS.

In a double-blind, randomized, placebo-controlled trial reported in 2014 by the Annals for Rheumatic Disease, people with active AS were randomized into three groups. They were treated with 20 mg of prednisolone, 50 mg of prednisolone, or a placebo. Treatments were administrated orally every day for two weeks.

The primary endpoint was a 50% improvement at week two. That end point was reached by 33% of the people treated with 50 mg and 27% of the people treated with 20 mg. The biggest improvements in disease activity were found using 50 mg prednisolone.

Conventional DMARDs

DMARDs can protect joints by blocking inflammation. There are two types of DMARDs—conventional (or nonbiological DMARDs) and biologic drug therapies.

Conventional DMARDs are considered second-line treatments for ankylosing spondylitis. They work by interfering with inflammation-producing processes. By blocking inflammation, they can prevent joint damage.

DMARDs like methotrexate and sulfasalazine are useful for treating different types of inflammatory arthritis. However, there is no evidence that conventional DMARDs provide any clinical benefit for spine disease. On the other hand, they may be effective in treating the arthritis of knees or hips that can be affected by ankylosing spondylitis.

Biologic DMARDs

Biologic DMARDs (often called “biologics”) are used in severe cases of AS where conventional DMARDs were ineffective in suppressing the effects of AS. Biologics might be given in combination with methotrexate or other conventional DMARD.

These drugs are genetically engineered medicines that target specific proteins in the body. Biologics can relieve pain and stiffness and might prevent disease and disability associated with AS.

Two types of biologic DMARDs, including tumor necrosis factor inhibitors (TNF inhibitors) and interleukin inhibitors, are believed to be effective for treating AS.

TNF Inhibitors

Research shows that treating AS with a TNF inhibitor can improve clinical symptoms of AS and slow down the processes that cause joint damage. Biologics used to treat AS might include adalimumab, infliximab, etanercept, and golimumab.

Interleukin (IL) Inhibitors

Two IL-17 inhibitors—Cosentyx (secukinumab) and Taltz (ixekizumab)—are approved by the U.S. Food and Drug Administration (FDA) for treating AS. Like TNF inhibitors, IL-17 inhibitors work by targeting specific inflammatory proteins and their processes to reduce inflammation.

While these medications pose an increased risk for infection, they are highly effective in improving AS symptoms.

JAK Inhibitors

Janus kinase inhibitors, also known as JAK inhibitors, are a type of medication that inhibits the activity of one or more of the Janus kinase family of enzymes. By targeting these enzymes, JAK inhibitors can taper down the effects of your overactive immune system to ease pain and swelling and prevent joint damage.

There are currently three JAK inhibitors available in the United States: Xeljanz (tofacitinib), Olumiant (baricitinib), and Rinvoq (upadacitinib). The FDA has approved all of them for treating another type of inflammatory arthritis, rheumatoid arthritis.

While Rinvoq received FDA approval as a treatment for AS in 2022, Xeljanz and Olumiant are not yet approved, and researchers continue to examine the effects of these treatments in people with AS.

A study reported in 2019 randomly assigned 187 patients with AS to one of two groups. One group was given 15 mg of upadacitinib, and the other group was given a placebo. After 14 weeks, 52% of the people taking upadacitinib had improvements in disease activity of up to 40%.

It is uncertain whether all currently available JAK inhibitors will be approved for treating AS, but studies to date are promising. Much like DMARD treatments for AS, these medications suppress the immune system, which means they increase infection risk. Use of JAK inhibitors also come with other possible risks, including serious heart-related events, cancer, blood clots, and death.

However they are just as effective as biologics, can be taken orally (as a pill), and work fast.

Surgery

Most people with AS won’t need surgery. However, if you experience severe pain or have severe joint or spine damage, your healthcare provider might recommend surgery to repair the affected areas, reduce pain, and improve your mobility and function.

People who might need surgery for AS include those who:

• Have severe pain that can’t be controlled with treatment, including pain medications
• Have spinal fractures
• Struggle to lift their head and look forward because of spinal fusion
• Have numbness and tingling in the arms or legs because of pressure to the spinal cord and nerves
• Have limited motion of the hip area and pain with having to bear weight on the hip

Procedures often performed on people with AS might include:

Hip replacement: According to a 2019 review, up to 40% of people with AS experience hip involvement, and up to 25% will need a total hip replacement. With a total hip replacement, the diseased parts of the hip joint are removed, and the ends of the hip socket and thigh bone are replaced with artificial parts.

Osteotomy: In cases where the spine has fused, an osteotomy may be used to repair a curved vertebra and straighten the spine. This procedure aims to eliminate any compression at the nerve roots and stabilize and fuse the spine.

Laminectomy: A laminectomy is done to relieve pressure on the spinal nerve roots. This procedure involves removing the lamina (of the vertebra) to access the disk. A laminectomy is a minimally invasive procedure that can be done in less than two hours.

While there aren’t any specific prevalence studies on the surgical need for AS, studies have confirmed surgery can reduce pain and disability, improve mobility and function, and minimize the effects of muscle fatigue. Surgical intervention can also restore balance and improve respiratory and digestive restrictions caused by AS.

Treatment of Disease Complications 

Treating AS also involves treating complications as they occur.

Uveitis

Uveitis is the most common nonjoint complication of AS. It is a type of eye inflammation that affects the uvea of the eye­­—the middle layer of tissue of the eyewall. Symptoms include eye pain, blurred vision, and eye redness.

Uveitis is treated with medications that reduce inflammation, including corticosteroid eye drops. Your healthcare provider might also prescribe eye drops that control eye spasms, antibiotics if there is an infection, and additional treatments to manage the underlying cause (AS).

Cauda Equina Syndrome

Cauda equina syndrome (CES) is a rare neurological complication that might affect people with long-standing AS. It occurs when the bottom of the spine becomes compressed.

Symptoms of CES might include pain and numbness of the lower back, weakness of the legs affecting the ability to walk, and inability to control bladder or bowel function.

Amyloidosis

Amyloidosis (AA) can affect people with AS. It is a condition where the protein amyloid builds up in the organs. It can cause a wide range of symptoms, including severe fatigue, fluid retention, shortness of breath, and numbness or tingling of the hands and feet. Secondary AA is treated by managing the underlying cause and with corticosteroids.

Its frequency is about 1.3% in people with spondyloarthritis conditions like AS, and is often seen in people with long-standing disease. It is a dangerous complication of AS and can lead to death if left untreated.

Traumatic Fracture or Dislocation

Another very serious complication is traumatic fracture/dislocation that can cause significant consequences if not diagnosed. Patients with ankylosing spondylitis who injure their head or neck should be evaluated whenever possible with a CT scan to pick up any fractures that might not be seen on plain X-rays.

A Word From Verywell

Ankylosing spondylitis is a progressive disease with no cure. This means it will get worse with time. Treatment is key to slowing down the disease and keeping you active. Even long-standing and advanced ankylosing spondylitis is treatable and manageable.

Treatment is also vital for preventing complications and easing the effects of the disease. It is important to work with your healthcare provider to find a treatment plan that best addresses what you are experiencing with AS. Your treatment plan is central to your living a normal and productive life with and despite AS.