Managing Ankylosing Spondylitis During the COVID-19 Pandemic

Ankylosing spondylitis, also known as Bechterew's disease, is a systemic type of arthritis that causes inflammation in the spine. While there is no cure for ankylosing spondylitis at the moment, people with this condition can benefit from taking medications to alleviate symptoms and control disease progression. Physical therapy is another important aspect of managing ankylosing spondylitis that can improve posture and spine mobility to prevent stiffening and decrease pain.

Accessing medical services can be challenging for people with this condition during the COVID-19 pandemic. While some drugs for ankylosing spondylitis can be self-administered, some have to be given through an IV in a medical office. Similarly, physical therapy requires a visit to a physical therapist's office. Thanks to technology, people with ankylosing spondylitis can now maintain their care through telehealth visits that are carried out virtually. If you have to venture outside, there are ways you can minimize your risk of COVID-19.

Ankylosing Spondylitis and COVID-19 Risk

People with ankylosing spondylitis who are being treated with immunosuppressive medications could be at increased risk of COVID-19. Research on this topic has been mixed, but it is important for those with ankylosing spondylitis to take extra precautions to minimize their risk of contracting COVID-19.

Immunosuppressive Medications

Tumor necrosis factor (TNF) is a specific cytokine, a cell signaling protein produced by the immune system, that causes inflammation throughout the body. Because TNF is elevated in patients with ankylosing spondylitis, TNF inhibitors such as Humira (adalimumab), Remicade (infliximab), Enbrel (etanercept), Cimzia (certolizumab pegol), and Simponi (golimumab) are commonly prescribed to lower the level of these proteins and reduce inflammation.

Biologics like TNF inhibitors, however, may increase the risk of infections and lower the body's ability to fight infections, including COVID-19 because of the medication’s effects of suppressing the immune system.

Interleukins, specifically interleukin-17 (IL-17) and interleukin-12/23 (IL-12/23), are also specific inflammatory cytokine proteins that are often elevated in autoimmune conditions like ankylosing spondylitis. Biologics like IL-17 and IL-12/23 inhibitors are also used to treat ankylosing spondylitis, but have the same immunosuppressive effect and the potential to increase the risk of infections.

According to a recent survey administered to 2,992 patients with ankylosing spondylitis, 16% changed their medication either by reducing their dosage or stopping their medication entirely due to fears of acquiring COVID-19. This change was most common among patients taking TNF-inhibitors, with 25% of patients reducing their use of these drugs.

While preliminary research suggests no significant difference in COVID-19 risk and severity of symptoms between the general population and patients with rheumatic conditions like ankylosing spondylitis being treated with biologic medications, further research is needed to determine if a relationship exists. Some researchers suggest that biologic medications increase the risk of only certain types of infections like hepatitis B, varicella zoster, or salmonella, without any specific link to the SARS-CoV-2 virus that causes COVID-19, but research is still ongoing.

Minimizing Risk

To minimize your risk of COVID-19 infection, the Centers for Disease Control and Prevention (CDC) advises those who may be at increased risk to:

• Stay up to date with COVID-19 vaccinations including boosters
• Wear a well-fitting mask or respirator indoors in public
• Avoid crowds and limit close contact with other people in public
• Avoid contact with people who have suspected or confirmed COVID-19
• Wash your hands with soap and water frequently, or use an alcohol-based hand sanitizer to clean your hands

Symptoms of COVID-19 may appear between two and 14 days after exposure, and can include:

• Cough
• Shortness of breath
• Fever
• Chills
• Loss of taste or smell
• Sore throat
• Headache
• Muscle or body aches
• Diarrhea
• Nausea or vomiting
• Congestion
• Fatigue

If you have any of these symptoms, it is best to get a COVID-19 test to determine if you have been infected. You can visit the website for your local or state health department to find a testing location near you. COVID-19 tests are typically covered by your health insurance or free if you are uninsured.

Patients should notify their healthcare provider if they are exposed to COVID, have symptoms of COVID, or are definitively diagnosed so recommendations can be made in terms of whether or not to hold their ankylosing spondylitis medications.

Treatment for Ankylosing Spondylitis During the COVID-19 Pandemic

It is important to continue with your prescribed treatment for ankylosing spondylitis, especially medications, throughout the COVID-19 pandemic to stay in good health and prevent an increased risk of ankylosing spondylitis relapse and worsening of symptoms.

Maintaining healthy lifestyle habits will also keep your immune system strong and decrease your risk of potential complications should you be exposed to the coronavirus. These include:

• Getting adequate, uninterrupted sleep at night for seven to eight hours
• Eating a healthy diet full of whole and unprocessed foods
• Staying adequately hydrated
• Exercising, including walking, at least three times per week
• Staying connected to family and friends for social support. Phone calls, Facetime, and Zoom video conferencing can all be used to stay in touch with loved ones to avoid direct in-person contact

Telemedicine

It is important to maintain your regular check-ups with your healthcare provider during the pandemic to stay on top of your condition and make adjustments to your treatment and medication dosage as necessary. When in-person visits are difficult to attend or pose an increased risk of potential exposure to COVID-19, telemedicine is an important asset for maintaining continuity of care for ankylosing spondylitis. 

Telemedicine, or telehealth, refers to the delivery of healthcare services virtually through telecommunications technology, primarily video conferencing. Telemedicine visits are generally approved by insurance companies as a useful substitute for in-person care with your healthcare provider or other healthcare providers. Telemedicine platforms utilize secure interfacing technology to ensure privacy, security, and protection of your personal health information.

The American College of Rheumatology promotes the use of telemedicine to increase access to care and improve quality of care for patients with rheumatic diseases, including ankylosing spondylitis, although virtual visits should not be used to replace in-person visits. According to a survey interviewing 2,210 participants, patients with ankylosing spondylitis, lupus, and cystic fibrosis reported the highest proportion of telehealth use compared with those with other underlying conditions.

Limitations

There are, however, certain limitations to what telemedicine can accomplish. The following cannot be done through a telehealth appointment:

• Physical exams
• Bloodwork
• Imaging
• Infusion treatments

If you are currently receiving infusion treatment for ankylosing spondylitis, consider asking your healthcare provider about the pros and cons of changing to a different medication that you can take at home if you wish to avoid in-person visits.

Uses

Despite some limitations, telemedicine visits can help your healthcare providers manage your ankylosing spondylitis by allowing them to:

• Assess your symptoms and changes over time
• Determine the effectiveness of your current treatment and make changes as needed
• Discuss the results of imaging and blood work results
• Track disease progression
• Answer questions about managing ankylosing spondylitis 

Certain providers are also able to deliver physical therapy virtually through telemedicine means, although it is most effective to attend physical therapy visits in-person so that your physical therapist can perform a physical exam and make corrections as you perform certain exercises.

Physical therapy clinics also have access to more space and equipment than you may have at home. If you are uncomfortable attending physical therapy visits two to three times a week as is commonly recommended, consider attending your initial evaluation in-person and following up with the remainder of your care via telemedicine visits and a home exercise program.

To help prepare for a telehealth appointment for ankylosing spondylitis, use our downloadable Doctor Discussion Guide below. It'll help you learn relevant terminology, anticipate questions you may want to ask, and more.

Ankylosing Spondylitis Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

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How to Safely Re-engage in Health Care

It is hard to say if and when we will be able to go back to normal life the way it was before the COVID-19 pandemic. That being said, your health and managing your symptoms of ankylosing spondylitis should still be top priorities during this uncertain time.

All healthcare facilities have enforced specific precautions and procedures to ensure the safety of their patients and reduce the risk of infection so that patients can continue to receive the care they need. These methods include:

• Making sure all staff and patients wear masks at all times 
• Limiting the number of people in the facility
• Physical distancing staff and patients when possible
• Frequently disinfecting commonly used surfaces and equipment
• Sanitizing used chairs and examination tables between patients
• Screening each patient for potential COVID-19 exposure and checking temperatures
• Providing increased access to hand sanitizers and disinfectant wipes throughout the facility

Because proper diagnosis and management of ankylosing spondylitis require in-person interactions with healthcare providers to carry out physical examinations, medical imaging, bloodwork, infusions, and physical therapy, it is important to continue to follow up with your healthcare provider and use alternative means like telemedicine visits to supplement your care only when appropriate. 

COVID-19 Vaccine

Phase three of clinical trials for COVID-19 vaccines did not include those who may be immunocompromised, such as patients with ankylosing spondylitis taking biologics and other immunosuppressive medications.

The COVID-19 vaccines manufactured by Moderna and Pfizer-BioNTech currently approved by the U.S. Food and Drug Administration (FDA) are mRNA vaccines. The Novavax COVID-19 Vaccine is a protein subunit vaccine, and the Johnson & Johnson/Janssen (J&J) COVID-19 Vaccine is an adenovirus vector vaccine. They both have emergency use authorization (EUA) from the FDA. None of the currently FDA-approved or FDA-authorized COVID-19 vaccines contain live or weakened forms of the virus.

Live virus vaccines can be potentially problematic for patients with weakened immune systems, including those with ankylosing spondylitis. But because the approved COVID-19 vaccines either utilize mRNA technology or are protein-based, there is no evidence at this time that suggests the vaccine increases the risks of getting COVID-19 or having more side effects from the vaccine among patients with ankylosing spondylitis.

Medical experts from the Spondylitis Association of America say that patients with ankylosing spondylitis taking biologics like TNF inhibitors can safely be vaccinated for COVID-19, although they may experience a decreased response to the vaccine. Because people taking biologic medications have suppressed immune systems, they do not have the same physiological response to vaccines as people in the general population.

As a result, the vaccine may provide less protection against COVID-19 for these people with ankylosing spondylitis. Therefore, the CDC recommends those who are moderately or severely immunocompromised and received two doses of an mRNA COVID-19 vaccine receive a third primary dose of the same vaccine, as well as an updated mRNA bivalent booster.

Those who received 1 dose of the J&J vaccine as the primary vaccination should get a dose of an mRNA vaccine at least 4 weeks later and then get a bivalent booster at least 2 months after the last dose. 

Those who received the Novavax COVID-19 vaccine series should get a bivalent booster at least two months after the second dose or last booster. 

In limited situations, people ages 18 years and older who have completed the primary COVID-19 vaccination and have not received any previous booster doses may receive a monovalent Novavax booster dose if they cannot receive an mRNA vaccine. This dose is given at least 6 months after completing the primary series. 

A Word From Verywell

Taking care of your health and managing ankylosing spondylitis should continue throughout these unpredictable times. It is important to follow through with your treatment to stay healthy, consider getting the COVID-19 vaccine to boost your immunity, and continue to practice mask wearing, disinfecting, and social distancing to decrease your risk of COVID-19 infection.

When in-person visits are difficult to attend or when virtual visits can effectively replace office follow-ups, consider using telemedicine visits to maintain communication with your healthcare providers and continuity of care throughout the COVID-19 pandemic.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.