How Ankylosing Spondylitis Is Treated
While there is no cure for ankylosing spondylitis (AS), a treatment regimen that consists of physical therapy and medication can effectively ease a person’s symptoms of joint pain, stiffness, and swelling, and also improve everyday functioning. The American College of Rheumatology (ACR) created guidelines for treating ankylosing spondylitis that were meant to help doctors optimize the care of their patients with AS in a systematic way, based on research studies.1
As a person with AS (or as someone with a friend or family member who has AS), knowledge about treatment guidelines will help you navigate this complex and chronic disease more confidently.
Treatment types for ankylosing spondylitis
Illustration by JR Bee, Verywell
Quitting smoking is an essential component for improving symptoms from ankylosing spondylitis. Evidence suggests that smoking may exacerbate disease symptoms.2
Exercise is also an important part of treatment for ankylosing spondylitis. Daily exercise can help decrease symptoms and increase your mobility, flexibility, and strength.3 Practicing good posture may also help prevent long-term complications. Your doctor can help you develop an exercise plan that is safe and effective for you.
10 Exercises for AS
In addition to medication, the American College of Rheumatology recommends physical therapy for people with active AS (meaning those who have symptoms of inflammation like joint pain and stiffness).
A number of studies have found physical therapy to be beneficial in reducing pain and improving spinal mobility, posture, flexibility, physical functioning, and well-being.
The good news is there is little harm associated with physical therapy. Also, a person can engage in exercises and stretches at home or within a group setting. However, research does suggest that supervised group physical therapy may be more beneficial than home exercises.3
What may be even more appealing (and luxurious) for those with AS is a type of therapy called spa-exercise therapy. This type of therapy includes exercising in warm water, undergoing a massage from hydrotherapy jets, and relaxing in a steamy sauna.
In fact, research has found that spa-exercise therapy combined with group physical therapy is better than group physical therapy alone.
Over-the-Counter (OTC) Therapies
Non-Steroidal Anti-Inflammatory (NSAID) Therapy
The mainstay treatment for ankylosing spondylitis is non-steroidal anti-inflammatory (NSAID) therapy. NSAIDs have been around a long time and are very effective at reducing inflammation in the body. They work by blocking enzymes called cyclooxygenase enzymes (COX enzymes).
By blocking these enzymes, prostaglandin levels are reduced in the body. Since prostaglandins play a key role in inflammation, by reducing them, symptoms of inflammation like pain and swelling are minimized. However, NSAIDs aren’t a viable treatment for all.
NSAIDs cannot be taken by everyone due to their potential for harm. It’s important to only take an NSAID under the guidance of your doctor.
For instance, one well-known potential harm of NSAID therapy is that it may cause stomach damage, ulcers, and bleeding. NSAIDs can also increase your risk of heart attack, heart failure, or stroke. They may also raise a person’s blood pressure and cause or worsen kidney problems.4
In addition to these potential harms, NSAIDs may interact with your other medications. This is why it is important to tell and ask your doctor about all of the medications you are taking, including herbals, vitamins, or supplements. There are a number of different NSAIDs available to treat AS, including both over-the-counter NSAIDs and prescription NSAIDs. Examples include:1
over-the-counter NSAIDs: Advil or Motrin (ibuprofen) and Aleve (naproxen)
prescription NSAIDs: Voltaren (diclofenac), Mobic (meloxicam), or Indocin (indomethacin)
Over-the-counter NSAIDs like ibuprofen are also available by prescription at a higher strength. Another type of NSAID commonly prescribed to treat AS is Celebrex (celecoxib), which is designed to limit stomach and intestinal problems.
Tumor Necrosis Factor Inhibitors (TNFi)
If a person with AS cannot take an NSAID, or if their symptoms like pain and stiffness are not improved with NSAID therapy, a TNF blocker is usually recommended. Tumor necrosis factor (TNF) is a protein involved in the inflammatory process, so by inhibiting its production, inflammation in the body is reduced.
The good news about TNF blockers is there is ample scientific evidence to support their benefit in reducing disease activity in ankylosing spondylitis—in other words, quieting the inflammation down in the body.5
TNF blockers are not completely benign therapies. They do have risks, and this must be weighed carefully for each person.
Due to the fact that TNF blockers suppress a person’s immune system (albeit an overactive one in the cases of those with ankylosing spondylitis), they can increase a person’s risk of both mild infection and serious infection. An example of a mild infection is a common cold. On the other hand, a serious infection that doctors especially worry about when a person is taking a TNF inhibitor is tuberculosis.
Due to the risk of tuberculosis reactivation, a TB test is required before initiating TNF blocker therapy. Rarely, TNF blockers have been linked to an increased chance of developing certain cancers.
It’s also important to know that certain people are not candidates for taking TNF blockers. Conditions that would prevent a person from being able to take TNF blockers would be considered contraindications.
Contraindications for TNF Blockers
An active infection like pneumonia
Women who are pregnant or breastfeeding may not be candidates for TNF blocker therapy.
According to current medical guidelines, a person should only be considered for a TNF blocker if their disease does not improve with at least two different types of NSAIDs (at a maximum dose tolerated).6
The TNF blockers used to treat ankylosing spondylitis are:
Remicade and Renflexis (infliximab)
Remicade, Inflectra, and Renflexis (infliximab) are given as an infusion through the vein, while Enbrel (etanercept), Humira (adalimumab), Simponi (golimumab), and Cimzia (certolizumab) are given as subcutaneous (into the fat tissue) injections.
If a person does not respond well to a TNFi, their doctor may consider Cosentyx (secukinumab). Cosentyx was approved by the US Food and Drug Administration (FDA) to treat active ankylosing spondylitis.
It works by blocking IL-17A, which is a proinflammatory cytokine (a molecular messenger that induces an inflammatory response in the body). IL-17A is known to play a major role in the development of AS.
Cosentyx is given subcutaneously once a week for four weeks, and then every four weeks thereafter. Research suggests that it’s well-tolerated, with the most common adverse effect being cold symptoms, like a runny nose and sore throat.
Research is still evolving on Cosentyx. Nonetheless, it’s exciting there is now an option for people whose disease continues to worsen on a TNF inhibitor or who cannot take a TNF inhibitor.7
In rare instances, surgery is needed to treat ankylosing spondylitis. This is usually reserved for people with severe hip joint damage and pain. In these instances, a total hip replacement is often recommended over no surgery at all.
Riskier surgeries like those involving the spine are much less common and performed when there is severe downward curving of the spine (“hunchback posture”).
Some people choose to pursue alternative methods in addressing their AS as well. These methods have not been through the rigorous studies necessary for drug approval. However, some people with AS have reported benefits from the following:8
transcutaneous electric nerve stimulation (TENS)
It is important to note that the effectiveness of these therapies has not been established. Chiropractic treatment, in particular, is a concern of mainstream physicians, who worry that it might lead to complications such as spinal fractures.
Ankylosing spondylitis is a chronic disease, and there is no cure yet. However, there are ways to manage it. With the right treatment regimen (which will need tweaking over time under your doctor’s guidance), you can live well with AS.