Ankylosing Spondylitis (AS) Treatment Options

Ankylosing spondylitis is treated with a combination of medication, exercise, physical therapy, and sometimes surgery.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually the first drug treatment offered for ankylosing spondylitis, according to a paper published in Advances in Pharmacological Sciences.

One class of drugs called tumor necrosis factor (TNF) alpha-blockers can also be very effective for ankylosing spondylitis, as can another type of drug called IL-17 inhibitors, which work similarly to TNF alpha-blockers (by preventing the inflammation that leads to symptoms).

If these drugs don’t work, a class of drugs called Janus kinase (JAK) inhibitors may be prescribed.

In some cases, doctors may prescribe other drugs that work similarly to reduce inflammation but haven’t yet been approved specifically for ankylosing spondylitis.

The goals of ankylosing spondylitis treatment are to reduce inflammation, with the hope of reducing the tissue damage that results from inflammation, improve physical functioning, and reduce pain and other symptoms of the disease.

In August 2019, the American College of Rheumatology updated its Recommendations for the Treatment of Ankylosing Spondylitis (AS) and Nonradiographic Axial Spondyloarthritis (nr-axSpA) to help both physicians and their patients living with these forms of arthritis understand their treatment options.

NSAIDs Reduce Inflammation

NSAIDs reduce inflammation and accompanying pain. Those used to treat ankylosing spondylitis include:

Indomethacin (Indocin)
Ibuprofen (Motrin, Advil)
Naproxen (Aleve, Naprosyn)
Meloxicam (Mobic)
Diclofenac (Voltaren)

One drawback of NSAIDs is that they can cause gastrointestinal bleeding. They should also be used with caution if you have high blood pressure or cardiovascular disease.

A study published in Arthritis Care & Research found that patients with ankylosing spondylitis who took NSAIDs regularly were 12 percent more likely to develop high blood pressure compared with those who rarely used the drugs.

To prevent this, people are advised to take the smallest daily dose that provides adequate relief.

One class of NSAIDs called COX-2 inhibitors have a lower risk of bleeding than traditional NSAIDs. One COX-2 inhibitor, celecoxib (Celebrex), is still being used to treat ankylosing spondylitis. Rofecoxib (Vioxx) caused a high rate of heart attack and was thus pulled from the market in 2004.

TNF Alpha-Blockers Target Underlying Cause of Inflammation

If you find that NSAIDs don't provide enough relief, or if side effects become a problem, your doctor may prescribe a TNF alpha-blocker, also known as a TNF inhibitor or anti-TNF drug.

TNF alpha-blockers are biologic drugs that are used to treat rheumatoid arthritis and some other forms of inflammatory arthritis. They reduce inflammation and stop disease progression by targeting an inflammation-causing protein called “tumor necrosis factor.”

According to the Spondylitis Association of America, they have been shown to be very effective in the treatment of ankylosing spondylitis.

The five TNF alpha-blockers approved by the U.S. Food and Drug Administration (FDA) for use in people with ankylosing spondylitis are:

Adalimumab (Humira)
Certolizumab (Cimzia)
Etanercept (Enbrel)
Golimumab (Simponi)
Infliximab (Avsola, Inflectra, Remicade, Renflexis)

TNF alpha-blockers must be injected or infused intravenously.

These drugs are expensive, and they raise the risk for infection, including reactivation of latent tuberculosis. They also reduce the ability to fight infections.

TNF alpha-blockers were once thought to increase a person’s risk of melanoma (a type of skin cancer). But a systematic review of the literature published in JAMA Dermatology could only conclude that an increased risk from biologic drugs, including TNF alpha-blockers, cannot be ruled out.

A study published in Clinical Rheumatology found that patients with rheumatoid arthritis who used anti-TNF drugs had an increased risk of nonmelanoma skin cancer, though the study didn’t look at patients with ankylosing spondylitis.

Biologic Drugs Target Different Inflammatory Proteins

Another class of biologic drugs that can be used to treat ankylosing spondylitis are called IL-17 inhibitors.

These drugs prevent inflammation by binding to interleukin-17A (IL-17), a protein that is released by certain immune cells and that normally activates inflammation in the body as part of its immune response. In people with ankylosing spondylitis, however, the numbers of interleukin-17-producing cells are higher than normal, leading to excessive inflammation.

The two IL-17 inhibitors approved by the FDA for use in people with ankylosing spondylitis are:

Secukinumab (Cosentyx)
Ixekizumab (Taltz)

Both secukinumab and ixekizumab are self-injected beneath the skin using a prefilled syringe or injection pen. They’re given weekly at first, then monthly, according to the American College of Rheumatology.

These drugs are also used to treat moderate to severe plaque psoriasis and psoriatic arthritis.

Similar to TNF alpha-blockers, IL-17 inhibitors are associated with a higher risk of infection and a reduced ability to fight infections. In clinical studies, both secukinumab and ixekizumab also raised the risk of the onset or exacerbation of inflammatory bowel disease.

A study published in The New England Journal of Medicine found secukinumab to be effective in people who have not previously tried TNF alpha-blockers, as well as those who had not experienced symptom relief while using them.

Research has also found that secukinumab and ixekizumab were more effective than placebo in treating ankylosing spondylitis, though the drugs increase the risk of nonsevere infections.

The ACR’s treatment guidelines, however, recommend using IL-17 inhibitors only if TNF alpha-blockers are tried and found ineffective for an individual.

JAK Inhibitors Target the Production of Inflammatory Proteins

Janus kinases (JAK) are enzymes involved in immune system responses — their intracellular signals stimulate immune cells to produce inflammatory proteins. In autoimmune conditions like ankylosing spondylitis, overactive JAK signaling causes persistent inflammation.

A class of synthetic (nonbiologic) drugs called JAK inhibitors interrupt JAK signaling, reducing inflammation and slowing down the progression of the disease.

In December 2021, the FDA approved the oral form of the JAK inhibitor tofacitinib (Xeljanz) for the treatment of adults with active ankylosing spondylitis who have had an inadequate response or intolerance to one or more anti-TNFs.

And in April 2022, the agency approved the JAK upadacitinib (Rinvoq) for the same indication.

In clinical trials, about 40 percent of ankylosing spondylitis patients taking tofacitinib and 50 percent taking upadacitinib achieved a 40 percent improvement in their disease.

However, the FDA requires the labeling of both drugs to include a warning that the drugs increase a person’s risk of serious heart-related events, such as heart attack or stroke, cancer, blood clots, and death.

Corticosteroids for Joint Swelling and Eye Inflammation

If you have swelling in one or more joints, you may benefit from an injection of a corticosteroid into the joint or the tendon sheath (the membrane surrounding the tendon).

Corticosteroids aren't recommended for joint swelling that's widespread, and oral steroids aren't recommended for ankylosing spondylitis.

Steroid eye drops are used to treat uveitis, an inflammation of the eyes that occurs in 40 percent of people with spondyloarthritis, according to the American College of Rheumatology.

The anti-TNF drug adalimumab (Humira) can also be used to treat uveitis.

Because uveitis can damage your eyes even before you notice any symptoms, regular checkups by an eye doctor are recommended if you have been diagnosed with ankylosing spondylitis.

Exercise Key to Staying Fit and Flexible

Staying physically active is important for maintaining joint and heart health. Exercise can help you maintain more of the mobility and flexibility you would otherwise lose to ankylosing spondylitis. It can improve posture, stiffness, pain, fatigue, and breathing capacity.

Your doctor may refer you to a physical therapist, who can teach you special exercises to maintain flexibility and an upright posture when sitting and standing.

There are four main types of exercises recommended for ankylosing spondylitis:

Balance
Range-of-motion or stretching
Strengthening
Aerobic or cardiovascular

Your physical therapist may also be able to advise you on sleeping positions to help you get a better night's rest.

Performing breathing exercises is important, too. Ankylosing spondylitis can cause scarring in the lungs due to inflammation and can also limit how much your chest can expand with inhalation.

Doing deep-breathing exercises every day can help you prevent further stiffening of the ribs and maintain your ability to exercise.

RELATED: Breathing Exercises for Ankylosing Spondylitis

Surgery Reserved for Fractures and Severe Movement Restrictions

Spinal surgery is rarely performed on people with ankylosing spondylitis, except in the case of a fracture or if a person cannot straighten their neck.

You may benefit from joint replacement surgery, however, if your hips or knees have been severely damaged by the disease. Total hip replacement can help with hip pain and disability.

RELATED: Joint Replacement for Ankylosing Spondylitis: Why and When?

How to Cure Ankylosing Spondylitis Naturally

While there are no cures, natural or otherwise, for ankylosing spondylitis, there are actions you can take at home to help reduce pain and stiffness, including the following:

Daily Moist Heat or Cold Applications

Applying moist heat pads to sore muscles and stiff joints several times each day can ease pain and stiffness. Alternatively, spend time in a hot shower or bath, or soak in a hot tub. If you don’t like moist heat, try ice applications or cold packs on painful areas. Just be sure not to place ice on your bare skin. Instead, cover your skin with a towel to avoid getting frostbite, and only leave an ice pack in place for about 10 minutes at a time.

Inflammation-Fighting Food

Processed foods and saturated fat can cause inflammation, while a diet rich in fruits, vegetables, whole grains, and omega-3 fatty acid-rich foods (like fatty fish) may help reduce inflammation. Some specific foods with anti-inflammatory properties includes leafy greens, broccoli, onions, berries (blackberries, blueberries, raspberries, strawberries), wild salmon, healthy oils such as olive oil and avocado oil, and nuts and seeds, especially walnuts, almonds, peanuts, pistachios, chia seeds, and ground flaxseeds.

Stretching Exercises

According to Mayo Clinic, stretching exercises and range-of-motion movements can help with flexibility and encourage good posture.

A physical therapist can teach you specific stretches and range-of-motion exercises for the back, buttocks, hips, neck, shoulders, and any other painful or stiff part of your body. Remember that a stretch should feel like gentle tension, not pain. Similarly, when doing range-of-motion exercises, move the joint to the point of resistance, but not beyond that.

Laughter

Humor has long been used as a natural way of treating or coping with illness. In his memoir Anatomy of an Illness as Perceived by the Patient, the editor and writer Norman Cousins describes how in 1964, he lay seriously ill in a hospital with acute symptoms of what was later diagnosed as ankylosing spondylitis. When the medication prescribed by his doctors caused intolerable side effects, he devised his own treatment program, which included watching episodes of the TV show Candid Camera and Marx Brothers movies, as well as reading humor books, to make him laugh. And gradually, his symptoms began to recede, as did his markers of inflammation.

Cousins is not the only person who has found laughter therapeutic. A study published in the Baylor University Medical Center Proceedings noted that others, including the writer Joseph Heller and the scientist Stephen J. Gould, also used humor to raise their spirits when facing serious illnesses.

And Dr. Hunter D. “Patch” Adams believes in the concept so much that he wore a clown costume for 45 years to cheer up and help heal critically ill patients, including children. Adams said, “Comic relief is a major way for happy folk to dissipate pain.”

While laughter might help with reducing inflammation, research shows that stress can cause excessive inflammation by activating inflammatory responses in the brain.

Yoga

According to the National Center for Complementary and Integrative Health (NCCIH), people who do yoga report the following benefits from doing it:

Reduced stress
Increased relaxation
Feeling better emotionally
Feeling motivated to eat better and exercise more regularly

Other research funded by the NCCIH showed that doing yoga regularly helps chronic low back pain about as much as physical therapy does.

The American College of Physicians' guidelines for low back pain include yoga as a treatment for chronic low-back pain, according to a paper published in the journal Annals of Internal Medicine.

Other Mind-Body Methods

Some other nondrug approaches that may help to alleviate pain and stiffness include:

Cognitive behavioral therapy
Exercise
Mindfulness-based stress reduction
Motor control exercise, or exercises aimed at strengthening the muscles of the torso that support the spine
Multidisciplinary rehabilitation
Operant conditioning therapy, a form of behavioral therapy that focuses on positive or negative reinforcement
Progressive relaxation, a technique for easing muscle tension and anxiety
Tai chi

Some of these techniques you can do on your own, such as exercise, tai chi, and progressive relaxation, while others require a trained therapist to administer them, such as cognitive behavioral or operant conditioning therapy. If any of these modalities interest you, speak to your doctor about what resources are available in your area and how to take advantage of them.

Additional reporting by Joseph Bennington-Castro.