The first line of treatment for ankylosing spondylitis is often an over-the-counter medication or a prescription nonsteroidal anti-inflammatory drug (NSAID), along with physical therapy. Another type of medication for ankylosing spondylitis that may be started soon after diagnosis is a disease-modifying anti-rheumatic drug (DMARD). These drugs are called “anti-rheumatics” because they were developed primarily for people with rheumatoid arthritis. For people with ankylosing spondylitis, certain types of DMARDs can do more than just relieve symptoms — these medications may be able to slow down the progression of the disease itself.
Different Kinds of DMARDs
Traditional DMARDs like methotrexate are chemical compounds that interfere with normal biochemistry to slow down processes involved in joint destruction. They have proved useful for people with joint pain, but they typically work best for people with inflammatory arthritis of the peripheral joints, not spinal inflammation, according to Nortin M. Hadler, MD, a rheumatologist and emeritus professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill. “NSAIDs make people feel better but do not affect the course of damage from disease,” Dr. Hadler says. “DMARDs are designed to slow down the progress of the disease but are not designed primarily for making you feel better.” Of course, slowing the progression of an aggressive, damaging disease will contribute to less pain over time, he adds. However, these traditional chemical DMARDs are being used less in people with ankylosing spondylitis, in part because the results can be disappointing and because they have been replaced by a new and growing class of DMARDs — lab-engineered antibodies, or proteins produced by the human immune system, that restrict critical proteins (cytokines) produced by the cells involved in joint inflammation and destruction, Hadler says. These biologic DMARDs, or simply biologics, have become the mainstay of treatment for ankylosing spondylitis that’s persistent and progressive despite NSAIDs and chemical DMARDs. “These drugs often may relieve pain and stiffness and can prevent the progression and consequent disability of ankylosing spondylitis,” Hadler explains.
Biologic DMARDs for Ankylosing Spondylitis
The first biologics used for ankylosing spondylitis were similar to those used in the treatment of rheumatoid arthritis. These were anti-TNF antibodies that targeted tumor necrosis factor alpha, a protein that causes inflammation. In 2016, the U.S. Food and Drug Administration approved another biologic, secukinumab, that takes aim at the IL-17 cytokine. A study published in December 2020 by the journal Rheumatology and Therapy found that a high proportion of secukinumab-treated patients entered a remission that lasted the length of the three-year study. Other biologic DMARDs targeting IL-17 and IL-23, which are both inflammatory cytokines, are currently being tested and hold promise for ankylosing spondylitis treatment, according to a research review published in January 2016 in Clinical & Experimental Immunology. The benefits of these targeted drugs may include fewer side effects, reduction in disease progression, and effective treatment for those who do not respond to available treatments, the researchers note. “You know whether you wake up with back pain in the morning but you do not know what’s going on internally,” Hadler says. “You can really see dramatic benefits and patients going into remission,” adds John M. Davis III, MD, MS, RhMUS, professor of medicine at the Mayo Clinic College of Medicine and Science in Rochester, Minnesota. “But some patients have only modest, weak, or no response.” However, for most patients biologics offer a better quality of life and manageable pain, Dr. Davis says. Those who have no response to the treatment may also have other sources of chronic pain, such as fibromyalgia, he adds.
When to Start a Biologic DMARD for Ankylosing Spondylitis
In the past, people with ankylosing spondylitis didn’t start biologic DMARD treatment until they experienced changes in the spine as seen on X-rays. However, now your doctor may start you on a biologic medication earlier rather than later to slow progression of the condition. “It’s a discussion between the physician and patient,” Hadler says. “For some people NSAIDs are sufficient. Exercise is key, too. I have turned patients into major swimmers. Many are living very well without any of these new drugs.” In other words, there’s no single path to treatment. You need to make an informed decision with your doctor. Magnetic resonance imaging (MRI) may allow earlier diagnosis of ankylosing spondylitis, too. Most doctors still recommend starting with an NSAID as the first-line treatment unless an MRI shows significant inflammation or you’re experiencing severe pain and stiffness. “I personally would want to see specific, diagnostic radiographic changes before giving a biologic to someone with back pain,” Hadler explains.
Benefits and Risks of Biologic DMARDs for Ankylosing Spondylitis
The main benefit of starting biologic treatment is that it can slow the progression of ankylosing spondylitis. But what about the risks of taking these drugs? If you are properly screened to make sure you have no other health issues that would be exacerbated by biologics, they are remarkably safe when given to someone who truly needs them, according to Hadler. Discuss the following with your doctor to make sure they are right for you:
Because they affect the immune system, biologics increase your risk for infection. If you develop an infection, your doctor may have you stop taking the medication for a while.If you’ve been exposed to tuberculosis or hepatitis, a biologic drug can activate that infection. You may need to be screened for these diseases before starting to take a biologic.You may be at higher risk for severe fungal infections.In rare cases, you may be at higher risk for some types of cancers, including white blood cell and skin cancers. Tell your doctor about any past history of cancer.You may not be able to take a biologic if you have heart failure or multiple sclerosis, based on observational data. Let your doctor know if you’ve been diagnosed with either of these conditions.
The Bottom Line on Biologic DMARDs
If NSAIDs aren’t helping manage the symptoms of ankylosing spondylitis, chemical DMARDs and biologics are options. The menu of these treatments is growing, each with nuances in efficacy, risk, and cost. Talk to your doctor about the risks and benefits. Furthermore, another class of drugs, the biosimilars, are proving to be another treatment option, Hadler says. These are small molecules designed as pills to mimic the efficacy of the biologics, which have to be injected. With new treatments emerging constantly, the need for productive patient-physician dialogue is ever more important, according to Hadler. In fact, the next new treatment could be oral Janus kinase (JAK) inhibitors, according to Davis. These drugs, which are already being used in people with rheumatoid arthritis, have produced good results in his own practice, he says. Whatever treatment you and your doctor choose, don’t neglect regular exercise as part of your regimen to support your medication plan and help preserve range of motion in your spine and your level of function. When inflammation is under control, physical therapy can have great benefits, Davis says. Additional reporting by Diana K. Rodriguez and Nina Wasserman
