By Anca Askanase, MD, as told by Hallie Levine
Ankylosing spondylitis can be a devastating disease. But the good news is that the future is brighter than ever. That’s why I’m so optimistic.
Physicians – including GPs – are now better informed about Ankylosing Spondylitis. Patients are therefore diagnosed earlier, which improves their prognosis. Often, patients in the early stages of the disease have no 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 there’s inflammation. In the past, the damage was already done by the time we made a diagnosis and started the minimal treatment options we had. We hunted the disease and tried to eliminate its effects instead of getting ahead of it and trying to stop it.
Biologics have revolutionized the treatment of ankylosing spondylitis over the past two decades. These drugs slow down certain cytokines, which are molecules that signal your cells to turn on inflammation throughout the body. Cytokines play an important role in preventing disease, but when overactivated, they can trigger inflammatory diseases such as Bechterew’s disease.
We have made a tremendous difference with these extraordinary tools at our disposal by changing the face of this disease. We’ve managed to not only scratch the surface of ankylosing spondylitis, but people who are able to achieve full symptom relief and lead normal lives. There’s still a lot to do, but it’s so wonderful to be able to tell patients they’re in remission. Drugs currently available include:
Anti-tumor necrosis factor therapy (TNF inhibitors). These were the first biologics approved for ankylosing spondylitis in 2003. They not only treat joint arthritis, but also inflammation of the intestines and eyes, as well as spinal arthritis. They weaken your immunity, leaving you at increased risk of infection, including tuberculosis (TB test required before starting). But many of my patients are seeing amazing results. If they don’t respond to one, they will often respond to another. There are currently five FDA-approved drugs for ankylosing spondylitis: Enbrel, Humira, Remicade, Simponi, and Cimzia.
Anti-interleukin-17 therapy (IL-17 inhibitors). This is a different class of biological drugs. Two are currently approved by the FDA: secukinumab (Cosentyx) and ixekizumab (Taltz). Because IL-17 inhibitors target different cytokines than TNF inhibitors, they are a good option for patients who do not respond to or cannot tolerate TNF inhibitors.
Although biologics are very successful, they don’t work for everyone. That’s why I’m so excited about Janus kinase (JAK) inhibitors, drugs traditionally used to treat rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis. They inhibit several cytokines that are critical to the progression of ankylosing spondylitis. While three are currently available in the United States — tofacitinib (Xeljanz), baricitinib (Olumiant), and upadacitinib (Rinvoq) — none have been approved for the treatment of ankylosing spondylitis. But that could change soon. A 2021 study published in the Annals of Rheumatic Diseases found that tofacitinib (Xeljanz) significantly improved symptoms such as fatigue, inflammation and back pain in patients with ankylosing spondylitis compared to those taking a placebo. Even better, JAK inhibitors are more convenient for humans than biologics because you can take them orally. Biologics must be taken via an injection at home or an IV at your doctor’s office.
Today, when I see people with ankylosing spondylitis, I emphasize to them that treatment — and prognosis — has changed dramatically in just two decades. People can work, start families and continue to enjoy their favorite sports and activities. Things that would have seemed unthinkable 15 years ago.
There is still no cure for ankylosing spondylitis, and there may never be. But at least people with the condition can now live long, productive lives. I am very confident that as we advance our understanding of the disease and gain a better understanding of where it comes from, we will make advances in therapies.
In the meantime, I help guide people to their best treatments, encourage exercise and participate in physical therapy, and suggest they eat an anti-inflammatory diet rich in healthy foods like fruits, vegetables, and oily fish is. If they do all of these, there’s a good chance they’ll be able to control the course of their disease instead of letting their ankylosing spondylitis control them.