Medical Management of Ankylosing Spondylitis
Medical Management of Ankylosing Spondylitis
In the following literature review the authors consider the available evidence for the medical management of patients with ankylosing spondylitis (AS), and they critically assess current treatment guidelines. Medical therapy for axial disease in AS emphasizes improvement in patients' pain and overall function. First-line treatments include individualized physical therapy and nonsteroidal antiinflammatory drugs (NSAIDs) in conjunction with gastroprotective therapy. After an adequate trial of therapy with two NSAIDs exceeding 3 months or limited by medication toxicity, the patient may undergo tumor necrosis factor-α blockade therapy. Response should occur within 6-12 weeks, and patients must undergo tuberculosis screening. Evidence does not currently support the use of disease modifying antirheumatic drugs, corticosteroids, or radiotherapy in AS.
Ankylosing spondylitis is a chronic, inflammatory rheumatic disease. Its pathogenesis involves the formation of syndesmophytes with resultant spinal ankylosis. The vertebral column transforms from a dynamic structure with ligamentous attachments into a rigid column of tubular bone housing the spinal cord and neural elements. Sacroiliitis, spondylitis, and enthesitis all contribute to characteristic inflammatory axial pain. Common extra-spinal manifestations of AS include peripheral arthritis (25-50%), uveitis (25-40%), inflammatory bowel disease (26%), and psoriasis (10%).
Genetic studies have demonstrated a strong association with the HLA-B27 gene with a resultant preponderance for populations at northern latitudes. The authors of recent epidemiological studies have estimated the prevalence rates to range from 0.4% among Alaskan Eskimos to 1.4% in Norway. Notably, men are 2 to 3 times more likely than women to suffer from AS. Peak age of onset is between 20-30 years, with an average 5-6-year delay in diagnosis reported in the literature.
The disease course, although highly variable, will progress to severe disability in one third of patients. Manifestations of AS symptoms include back pain and stiffness in adolescence and early adulthood, and impaired chest wall expansion and spinal mobility may result. Patients with AS experience higher work disability and absenteeism than those with rheumatoid arthritis and thereby suffer substantial direct and indirect economic costs.
Treatment goals in AS center around 3 central principles: 1) symptom relief, 2) functionality relative to activities of daily living and work performance, and 3) delay or avoidance of the structural damage responsible for physical impairments or deformity. To this end, the ASAS International Working Group, in collaboration with the EULAR, developed consensus guidelines for the medical management of AS. Ten propositions, ranging from diagnosis to physical therapy and medical management, emerged from a 3-round Delphi exercise from a panel of experts; heavy consideration was given to supporting literature for various treatment modalities.
In the following review we summarize the ASAS/ EULAR consensus recommendations and include a systematic discussion of relevant studies. Discussion will proceed from general considerations in AS, namely diagnosis and disease monitoring, to nonpharmacological management tools and available medications. Surgical management of AS will be discussed elsewhere.
Abstract and Introduction
Abstract
In the following literature review the authors consider the available evidence for the medical management of patients with ankylosing spondylitis (AS), and they critically assess current treatment guidelines. Medical therapy for axial disease in AS emphasizes improvement in patients' pain and overall function. First-line treatments include individualized physical therapy and nonsteroidal antiinflammatory drugs (NSAIDs) in conjunction with gastroprotective therapy. After an adequate trial of therapy with two NSAIDs exceeding 3 months or limited by medication toxicity, the patient may undergo tumor necrosis factor-α blockade therapy. Response should occur within 6-12 weeks, and patients must undergo tuberculosis screening. Evidence does not currently support the use of disease modifying antirheumatic drugs, corticosteroids, or radiotherapy in AS.
Introduction
Ankylosing spondylitis is a chronic, inflammatory rheumatic disease. Its pathogenesis involves the formation of syndesmophytes with resultant spinal ankylosis. The vertebral column transforms from a dynamic structure with ligamentous attachments into a rigid column of tubular bone housing the spinal cord and neural elements. Sacroiliitis, spondylitis, and enthesitis all contribute to characteristic inflammatory axial pain. Common extra-spinal manifestations of AS include peripheral arthritis (25-50%), uveitis (25-40%), inflammatory bowel disease (26%), and psoriasis (10%).
Genetic studies have demonstrated a strong association with the HLA-B27 gene with a resultant preponderance for populations at northern latitudes. The authors of recent epidemiological studies have estimated the prevalence rates to range from 0.4% among Alaskan Eskimos to 1.4% in Norway. Notably, men are 2 to 3 times more likely than women to suffer from AS. Peak age of onset is between 20-30 years, with an average 5-6-year delay in diagnosis reported in the literature.
The disease course, although highly variable, will progress to severe disability in one third of patients. Manifestations of AS symptoms include back pain and stiffness in adolescence and early adulthood, and impaired chest wall expansion and spinal mobility may result. Patients with AS experience higher work disability and absenteeism than those with rheumatoid arthritis and thereby suffer substantial direct and indirect economic costs.
Treatment goals in AS center around 3 central principles: 1) symptom relief, 2) functionality relative to activities of daily living and work performance, and 3) delay or avoidance of the structural damage responsible for physical impairments or deformity. To this end, the ASAS International Working Group, in collaboration with the EULAR, developed consensus guidelines for the medical management of AS. Ten propositions, ranging from diagnosis to physical therapy and medical management, emerged from a 3-round Delphi exercise from a panel of experts; heavy consideration was given to supporting literature for various treatment modalities.
In the following review we summarize the ASAS/ EULAR consensus recommendations and include a systematic discussion of relevant studies. Discussion will proceed from general considerations in AS, namely diagnosis and disease monitoring, to nonpharmacological management tools and available medications. Surgical management of AS will be discussed elsewhere.
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