Conventional Treatments For Ankylosing Spondylitis

CONVENTIONAL MEDICAL TREATMENTS FOR ANKYLOSING SPONDYLITIS

The following categories of drugs are most commonly used to treat Ankylosing Spondylitis under the umbrella of "Conventional Treatments":  NSAIDs, Steroids, DMARDs, Biologics and Pain Medications.  Below is an explanation of each category, a list of which drugs fall into that particular category, and information on the effectiveness and risks of each of the drugs.

NSAiD's -

Unfortunately, non steroid anti-inflammatory drugs are still some of the most commonly recommended drugs by traditional medical providers for Ankylosing Spondylitis.  This includes over-the-counter and prescribed anti-inflammatories such as:  Advil (IBUPROFEN), ARTHROTEC (Diclofenac and Misoprostol), NAPROSYN & ALEVE (Naproxen),  MOBIC (Meloxicam), INDOCIN (Indomethacin), VOLTAREN (Diclofenac), CELEBREX (Celecoxib) and others.  

While it is true that prolonged inflammation is definitely the primary culprit in the disease process for AS, and any good treatment protocol would address it,  NSAIDs carry significant risks to ones health, even for healthy individuals, but especially when taken over long periods of time or taken by patients with compromised health, such as those with AS.  

As an example, one commonly prescribed NSAID for Ankylosing Spondylitis describes some of these risks as: "May cause ulcers, bleeding, or holes in the stomach or intestine. These problems may develop at any time during treatment, may happen without warning, and may cause death. The risk may be higher for people who take NSAIDs for a long time, are older in age, or have poor health."

Inflammatory Bowel Disease (IBD) commonly is found in patients diagnosed with Ankylosing Spondylitis.  

In one study, gut inflammation could be demonstrated in 68% of patients with some form of Spondyloarthropathy (SpA), the family of diseases that include Ankylosing Spondylitis and other similar types of arthritis (1).  

 

The association between AS and gut lesions has been recognized for many years. This is thought to be due to the fact that many of the same genes that predispose someone towards developing AS also predisposes them towards developing IBD. 

Approximately two-thirds of patients suffering from SpA, including AS, are not aware that they have a compromised gut because they have not developed clinical symptoms yet, although the microscopic signs of gut inflammation is apparent upon biopsies (2,3,4).

 

Therefore, with the obvious link between AS and an already compromised gut,  avoiding the damaging effects of NSAIDs on the intestinal tract becomes especially important.   As the lining of the gut becomes more and more "leaky", the bacteria which are triggering the symptoms in the first place have easier and easier access to the blood stream, and will continue to activate the immune system and provoke flare ups.  

It's true that taking NSAIDs may address the symptoms of the moment and make a person feel better short term because of limiting the inflammation.  However, what is the price?  In the end, by further damaging the colon, you are exasperating the disease process.  Would it not make more sense, instead of taking something that damages the intestinal tract,  to take steps to try to HEAL the gut and find optional ways of controlling the inflammation, or better yet, find and eliminate the underlying causes of inflammation? 

 

In addition to raising concerns over the risks of increasing the permeability and jeopardizing the health of the mucosal lining of the gut, it also is concerning that an increased risk of strokes and/or heart attacks are associated with taking NSAIDs.

 

Individuals with Ankylosing Spondylitis are already known to have higher than normal risks for heart disease and strokes, but it is unknown if the increased risk is due to the disease process itself, or if it is due to the fact that so many patients with AS are taking NSAIDs.  Most likely it is a combination of the two factors that increases the risk. In fact, a study done in 2011 by Canadian researches discovered that having Ankylosing Spondylitis increases your risks for heart disease AND stroke by 25-60% (5).  

Even the FDA has warned the public about the cardiovascular risks involved with taking nonsteroidal anti-inflammatory drugs (NSAIDs).  In 2005 the FDA posted warnings that taking these drugs WILL increase the risk of having either a stroke or a heart attack.  But in July of 2015,  the FDA took further steps to strengthen the warnings after an expert panel reviewed additional information about NSAIDs and made the recommendation that stronger warnings are issued.

It should be noted that Aspirin is also in the category of an NSAID.  Although it DOES pose the same risks involved with intestinal damage that all other nonsteroid anti-inflammatory drugs pose, it is not known to cause an increased risk for heart attacks or strokes.  Still, because patients with Ankylosing Spondylitis need to work extra hard to protect and heal their gut lining and avoid damaging it further,  even taking Aspirin on a regular basis just for the purpose of reducing inflammation and pain should be avoided and replaced with other options.

Because of the high risk of intestinal damage that NSAIDs are known to be associated with, an attempt was made to create a different class of NSAIDs, known as COX-2 inhibitors (such as Celebrex or Celecoxib).  While it is true that these types of drugs seem to lessen the potential harm caused to the digestive tract, they still are associated with very serious cardiovascular risks.  In fact, some of them were pulled off the market (such as Vioxx) because of the high rate of heart attacks that were caused by the drug.  Sadly, Vioxx caused 140,000 known heart attacks in the United States during the short 5 year period that it was on the market.  This experience did raise awareness about the serious danger that NSAIDs pose from a cardiovascular perspective, and it did lead to further research studies that proved the risk is not only limited to Vioxx, but is associated with ALL NSAIDs.

 

Celebrex is still on the market, but the FDA has required them to post the strongest possible warnings that the FDA requires, known as "black box warnings", for serious cardiovascular thrombotic events that may be caused by the drug, including MI (myocardial infarcation) and strokes.

With the higher than normal risk for heart disease, strokes, and bowel lesions that patients with Ankylosing Spondylitis already carry, it becomes clear why NSAIDs should be avoided at all costs.  Yes, inflammation must be addressed, but this has been accomplished by many individuals using other approaches, without resorting to NSAIDs. How unfortunate that some medical providers often still use NSAIDs as their go to recommendation for treating the symptoms of Ankylosing Spondylitis.  

Steroids -    

Corticosteroids such as Prednisone, Cortisone and Hydrocortisone can be effective in some cases in relieving the symptoms of inflammation related to spondyloarthritis, but what is the cost?  

 

Some of the most commonly reported adverse effects associated with corticosteroid use include:  increase in total cholesterol, increase in triglycerides, potassium loss and electrolyte imbalances, fluid retention,  high blood pressure, high blood sugar (of special concern to patients with Diabetes), increased appetite and weight gain or anorexia and weight loss, adrenal insufficiency, hypothyroidism, blurred vision and cataracts, severe tiredness and weakness, mood and behavioral changes, such as aggression, agitation and irritability as well as confusion and dizziness. 

 

Steroids work by suppressing your immune system.  While this is the mechanism that provides some relief in an autoimmune condition, it also is the mechanism that causes potential problems.  By weakening your immune system, it makes you more likely to get infections, including viral, fungal and bacterial.  You have to be especially careful not to knowingly expose yourself to anyone who is sick.  A common infection that normally would not be dangerous can wreck havoc when the immune system is compromised.  Likewise, bacteria or yeast that are normally found in your body can overgrow without a fully functioning immune system to keep them in check.

The adverse affects of taking steroids long term are especially severe and dangerous.  The three categories of serious side effects that are most concerning for patients with Ankylosing Spondylitis include the cardiovascular side effects, the gastrointestinal side effects and the muscular skeletal side effects.

The cardiovascular adverse effects of steroids can include enlargement of the heart, congestive heart failure, cardiac arrest, a fast, slow or irregular heartbeat (arrhythmia), high blood pressure, myocardial rupture, tachycardia, and vasculitis.  If you read the "Symptoms" page of this website, you learned that patients with AS are at an increased risk for a cardiovascular event, including tachycardia, arrhythmia, heart attacks (myocardial infarction) and others. Therefore, taking any medication that further increases your risks for a cardiovascular event is playing with fire.

The second category of adverse effects from steroids that are especially concerning to the Ankylosing Spondylitis population are the muscular/skeletal side effects.  Long term use of steroids are known to thin the bones and can lead to osteoporosis, osteopenia, and an increased risk for compression fractures of the spine.  They also can weaken muscles and lead to tendon rupture (particularly of the Achilles tendon).  

 

Why is this of particular concern for an AS patient?  As discussed on our "Symptoms" page, these patients are at an increased risk already for fractures of the vertebrae.  The remodeling process of their skeletal system often leads to osteoporosis and osteopenia, combined with frail new bone segments growing in places where it is not suppose to be (forming bridges between the vertebrae).  The rigidity of the spine and it's inability to absorb impacts makes it susceptible to fractures. 

 

In addition to an increased risk of fractures, the Achilles tendon is sometimes inflamed in these patients and can be a target site for the disease process.  Since long term use of steroids increases the risks for spinal fractures and injury to the Achilles tendon, this is especially dangerous in a segment of people who already are at an increased risk for these events.    

And finally, the third category of adverse effects from steroid use that is especially concerning to AS'ers involves gastrointestinal reactions.  Long term use of steroids can cause damage to the gastrointestinal tract, including ulcers in the stomach or small intestine (peptic ulcers) that can lead to perforation and hemorrhage, as well as perforation of the large intestine (particularly in patients who have IBD or Inflammatory Bowel Disease), as well as ulcers in the esophagus, along with abdominal pain and irritation of the stomach and nausea.   A significant percentage of patients with AS already experience ulcers of the colon (sometimes without symptoms) and/or IBD. Therefore, a medication that puts this segment of the population at a higher risk for gastrointestinal adverse reactions, when they are already at a higher risk for these types of manifestations, would not be a preferred choice.

 

 

What About Steroid Injections?

Due to the very undesirable and significant side effects of steroid use, many patients completely avoid all oral doses.  But what about Corticosteroid injections?  These cortisone injections can be given into a joint, into the bursa, into a muscle, into the spine, into the blood, or into a tendon.  For the purpose of helping to relieve arthritis pain related to Ankylosing Spondylitis, the injections are typically given directly into the spine (epidural injection) or into the inflamed joint.

These injections can sometimes provide temporary relief of pain.  If they do achieve a benefit, the results are experienced more rapidly because the medication is delivered directly to the target site.  Because of the direct delivery method, injectible steroids reduce the exposure of the medication to the rest of your body and, therefore, reduce some of the widespread negative effects that can occur.  

 

The injections are NOT without risks, however, nor are they effective in all individuals or in all applications.  For a number of patients who elect to get steroid injections, they feel no benefit whatsoever.  Some do feel a benefit, but they may need multiple injections before they experience any measurable relief, and the possibility of side effects is increased with each injection.  Some patients actually experience what is called a "cortisone flare", which causes an increase in pain and inflammation that is worse than the condition it is suppose to be helping with.  How does that happen? The injected medication can form crystals inside the body.  These crystals trigger an inflammatory response.  The increase in pain probably will pass in 2-3 days, but the patient will be left with no benefit afterwards.

The short term use of injections still can alter a person's blood sugar, which is of note if the patient has Diabetes.  It also suppresses the body's ability to fight infections. Also, more specifically of concern to patients with Ankylosing Spondylitis, are the potential bone thinning effects of injections (osteoporosis) as well as a raise in blood pressure. The number of injections given, as well as the dose, effects the degree of the risks.

If the injections are given in a joint, which they often are, besides thinning the bones there is also the possible side effect of damaging the joint tissue itself (especially with repeated injections), thinning the cartilage of the joint and weakening the ligaments of the joint.  Since members of the Ankylosing Spondylitis population are already at an increased risk for Osteoporosis and/or Osteopenia (which increase the risk of fractures), it's understandable that many patients choose to avoid these treatment protocols that further increase the likelihood of weakening their bones and look for other viable options.

As mentioned, Corticosteroid injections that are given in the spine to attempt to relieve back pain and sciatica are called "epidural injections".  They are inserted into a specific location in the spinal canal using x ray guidance (fluoroscopy).  Extreme care must be given so as to not puncture or cause trauma to the spinal cord itself.  Therefore, they are typically delivered while the patient is under anesthesia.  All of the risks mentioned above apply to this type of steroid injection also, with other unique additional risks that include errant needle placement, or accidental puncture of the spinal cord.  Cord trauma can result in paralysis, weakness or numbness of limbs, persistent headaches and brain damage. Cervical (neck) vertebrae injections are known to have a higher injury rate, perhaps because the epidural space is more narrow in the cervical area, and it has an increased proximity to the spinal cord.   

 

Patients with AS sometimes have Plantar Fasciitis (heel pain) and inflammation of the Achilles tendon.  How about using steroid injections in these cases?  Corticosteroid injections are rarely used on the Achilles tendon because there is a significant risk of rupturing the tendon.  Also, the usefulness of these injections to relieve the symptoms of plantar fasciitis (heel pain) has not been demonstrated.   Therefore, it is rarely used for this purpose either.

After considering the disturbing and alarming risks involved with steroids, whether oral or injected, and the fact that they increase risks that patients with Ankylosing Spondylitis  already face, many patients decide to avoid this medication.  Again, just as in the case of NSAIDs,  they find the cost is just too high to use these methods for reducing inflammation.   However, the inflammation cannot be ignored and must be addressed.  Many have found significant pain relief using diet modification along with a patented pain-blocking device that is drug-free, and perhaps other complimentary treatment modes.  

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Disease Modifying Agents -   

Also called DMARDs, or Disease Modifying Anti-Rheumatic Drugs. The goal of these drugs is to modify, or slow down, the progression of the disease itself, rather than just relieve symptoms. There are a number of DMARDs on the market, but as their name suggests, most are used to treat Rheumatoid Arthritis (RA).   Sulfasalazine (Azulfidine), however, is an exception.  This DMARD is also found to be effective in treating Ankylosing Spondylitis. 

 

Sulfasalazine belongs to a class called "sulfa drugs" and is used in the treatment of Rheumatoid Arthritis, Ankylosing Spondylitis, and other autoimmune conditions.   It is a combination of salicylate (the main ingredient in aspirin) and a sulfa antibiotic.   It works to decrease pain and inflammation, reduce/prevent joint damage, and preserve joint mobility.  Although the drug reduces inflammation and contains a component also found in aspirin, it is not a NSAID.    Also, it is enteric coated.  This means that the medication does not release until it reaches the target site...your colon.   Although the exact mechanism of how it works and why it is effect is not completely understood, it is believed that it might be the antibiotic component of the drug that is predominantly effective, especially since there is evidence that the drug has an effect against a pathogen residing in the colon, namely the Klebsiella bacteria, that is implicated in the disease. 

 

Interestingly,  Sulfasalazine has been proven to have a successful affect against the Klebsiealla bacteria, reducing the body's antibodies against this particular pathogen.  Although antibodies against this bacteria have been proven to be higher among AS patients than among the general population, treatment by Sulfasalazine did effectively reduce them (6,7).

 

Sulfasalazine is especially effective for Ankylosing Spondylitis patients who also have peripheral involvement (shoulders, hips, fingers, toes, knees, ankles, jaw, feet).  However, beneficial effects have also been demonstrated in those with axial AS (8).  

 

For example, a study was conducted in the outpatient rheumatology departments of five Finnish hospitals.  85 patients with AS (55 with peripheral AS, and 30 with axial AS) were included in the trial. During a period of 26 weeks, Sulfasalazine was given to both groups.  The drug proved to be an effective treatment for both classes, although the most significant improvement was seen in the group with peripheral AS.  In addition to a reduction of early morning stiffness and spinal pain, along with a greater mobility of the spine, all of the laboratory tests measuring inflammation (ESR, C Reactive Protein, and immunoglobulin concentrations) showed statistically significant improvements.  By comparison, the placebo group showed no such improvements in their lab results. Thus, Sulfasalazine made significant positive changes in the parameters of inflammation and successfully altered the disease course (8).

There have been some studies which indicated a lack of evidence whether or not Sulfasalazine had a positive effect in treating the symptoms of Ankylosing Spondylitis.  However, it is important to note that Sulfasalazine doesn't work immediately. It may take up to 12 weeks before it begins working.  Therefore, to accurately weigh the effectiveness of the drug, any test used to judge its results would need to last 24 weeks or more in length (such as the one referenced above).  Otherwise, they are not long enough to gauge the actual effects of the drug.  Also, the subjects used should have ACTIVE Ankylosing Spondylitis so that improvements in symptoms can be measured.  

If a patient decides to try Sulfasalazine, it is good to remember the above (that it takes at least 12 weeks before it starts working).  Therefore, you need to give it a full 4 months before deciding if it is helping or not.  Some who find they get significant, but not 100%, relief of symptoms from diet modification are able to reach 100% by adding Sulfasalazine to their treatment protocol.  The effectiveness of Sulfasalazine is compounded when used alongside diet modification and appropriate exercises and stretches.  If occasional flare ups still affect the patient due to factors such as whether, stress, over-exertion, monthly hormone fluctuations, etc, then many have found relief by using patented drug-free pain relieving devices.  Visit our page that discusses Complimentary Treatments For Ankylosing Spondylitis.

 

Keep in mind, too, that with the entrance onto the marketplace of newer drugs, older ones such as Sulfasalazine, which have been in use for decades and are effective, are not as likely to be recommended any more by your Physician. They simply are more likely to prescribed whatever is the newest drug.  However, since Sulfasalazine is one of the drugs with the least known side effects, many patients decide to start with it before using some of the other more potent drugs that have more serious associated risks.  

 

Sulfasalazine is a drug also prescribed for Inflammatory Bowel Disease, such as Crohns or Colitis.  It has an anti-inflammatory effect on the colon. Why is this a benefit? A significant percentage of patients with Ankylosing Spondylitis also have Inflammatory Bowel Disease, and an even greater number have bowel inflammation and ulceration (with or without symptoms) that is not yet diagnosed.  Therefore, this drug can have a two-fold beneficial affect, addressing both conditions.

 

Some cautions:  You shouldn't take Sulfasalazine if you know that you have an allergy to salicylates (e.g. aspirin) or to sulpha (it contains a sulfa antibiotics).  Folic acid (vitamin B9) needs to be taken along with Sulfasalazine, because the drug can decrease how much folic acid your body absorbs.  

 

The most common side-effects, if any,  of Sulfasalazine are nausea, diarrhea, stomach discomfort, headache and skin rashes (likely due to an allergic reaction).

 

These side-effects usually occur during the first three months of treatment and often clear up if the dose is reduced. It's also good to know that taking Sulfasalazine can affect your liver in some patients (some patients find it best to avoid alcohol consumption). These effects can be picked up at an early stage by blood tests.  In fact, blood tests that monitor your liver are recommended once or twice a month in the beginning after you start taking the drug.  In very rare cases, bone marrow suppression occurs.  So in addition to monitoring the liver in the beginning, it is also good to monitor your blood count.

Biologics -  

Biologic medicines are unique in they way they are manufactured.  Rather than being manufactured by simply combining chemicals, as most medications are, they are manufactured instead within an actual living system (such as within a human, animal, bacteria, or yeast), genetically engineered from one of these living organisms.  These types of drugs are typically administered by injection or infusion.  As with most medications, they are not effective in all patients.  For the patients that do feel some improvement with the use of these drugs, it is not uncommon for the positive effects to be temporary, and for the drug to eventually become ineffective.   Many people see an initial period of improvement, and then experience a decline in the drug's effectiveness until eventually the drug does not seem to be working at all any more.  The exact reason why this occurs is not fully understood, but it is believed to be related to ADA (anti-drug antibodies) that your body creates in response to the drug.  

In a recent article from the British Journal of Dermatology entitled "Antidrug Antibodies in Psoriasis: A Systematic Review," researchers examined previous studies of biologic drugs to determine how ADAs interfere with the effectiveness of biologics.  In the process, they reviewed 25 different studies of biologics, with their focus on four specific medications: Remicade, Humira, Enbrel and Stelara.  All together, the studies included almost 8,000 patients.  The result?  They were able to identify a definite connection between ADAs and decreased patient response in Remicade and Humira.  The connection between ADAs with Enbrel and Stelara was not conclusive.  It's important to point out, however, that the study only considered the effects of taking the drug for up to one year. Sometimes a patient takes a biologic for 2 or more years before they experience the sudden ineffectiveness of the drug.

Once your body has created these antibodies against the drug (ADAs), it is not likely that you will be able to take the drug again and experience benefits, even if you wait a short while before trying to restart the drug.  This is because your body keeps antibodies "on file" once they are created so the next time you are exposed to whatever it is that your body deemed to be a threat, it can more quickly respond.  This is how someone who has once had a particular virus, such as chicken pox, is said to be "immune" now to the disease.  Your body has figured out how to defeat that harmful intruder and has stored the knowledge away in its database in the form of antibodies.  It can pull them out quickly next time you are exposed and doesn't have to waste time learning all over again from scratch how to defeat that threat.  

So what does someone do when their biologic stops working?   Typically, most conventional doctors will either switch them to a new biologic to start the process over again,  or th)ey will try adding another drug to go along with the biologic to see if that will sustain its ability to work (note: this also adds a new set of side effects and risks).

There are basically 2 types of Biologics used to treat AS:  TNF Inhibitors and IL Inhibitors (such as IL-17, IL-23, IL-12, etc).   What are IL and TNF, which these drugs block, as their name implies?   They are inflammatory cytokines.  These cytokines send signals to certain immune cells that direct them to activate inflammation throughout the body.  In patients with inflammatory arthritis such as Ankylosing Spondylitis, there is an overabundance of TNF and IL. The drugs work by blocking those signal pathways.

By blocking certain aspects of your immune system in order to impair its ability to respond with an inflammatory reaction, the result is a weakened immune system.  In fact, the tendency of these drugs to increase the frequency of infections is a serious and well known complication of biologics.  This includes fungal, bacterial and viral infections.  

 

Some viruses may lay dormant inside a person for many years and then become activated when the immune system is in a weakened state.  As an example, if you previously were exposed to hepatitis or tuberculosis,  then these conditions can become active upon taking a biologic.  

 

Suppressing the immune system also puts you at a higher risk for developing certain types of cancers, such as lymphoma and skin cancer. 

Besides the higher risk for cancer, one of the other most feared adverse reactions to biologic drugs are the increased risk for developing an autoimmune disease (in addition to the one that the patient is already being treated for with the biologics).  For example, there are reports of patients developing lupus, MS (multiple sclerosis), and psoriasis after the first injection. In fact, by 2013 over 1500 cases of autoimmune diseases induced, or caused, by biologics have been reported.  Overwhelmingly this occurred with anti-TNF drugs, but it also occurred with other biologics.  These include 50 different systemic and organ-specific autoimmune diseases.  As the use of biologics continues to expand, the number and the diversity of induced autoimmune disorders is also expected to increase (9).

 

This reaction is, indeed, paradoxical since biologics are used to treat autoimmune diseases, yet they have this risk factor for CAUSING autoimmune diseases.  One of the most common biologic-induced autoimmune disease is Lupus, which is frequently considered the Grand Daddy of all autoimmune diseases.  The autoimmune diseases associated with biological agents can appear during the first day of treatment, or they may appear after years of use.  But the average time before they appear is about 40 weeks.  Sadly, some of these induced autoimmune diseases led to death. The majority of the reported deaths were related to the development of Interstitial Lung Disease (an autoimmune disease that affects the lungs) (9).

Below we will discuss in more detail the 2 types of Biologics most commonly used:  TNF Inhibitors and IL-17 Inhibitors.

TNF Inhibitors:   

TNF stands for "Tumor Necrosis Factor.  The first TNF Inhibitor, Enbrel (Etanercept), was approved for treating AS in 2003.  It can be effective against spinal arthritis and arthritis of the joints, as well as the inflammation in the gut and eyes. Other examples of TNF blocking drugs include Humira (Adalimumab), Remicade (Infliximab), Simponi (Golimumab), and Cimzia (Certolizumab).  

Anti-TNF drugs are not effective in all cases.  In fact, they are frequently ineffective.  In one study of patients with AS, only half of the patients who try TNF-blocking therapies achieve improvement as high as 50%.  The remaining half of AS patients either achieve no improvement, or they experienced less than 50% improvement. (10) 

 

Women respond even more poorly to TNF inhibiting drugs than men.  A study conducted in 2018 demonstrated that only 52 percent of women who took anti-TNF drugs for their AS experienced an improvement no higher than 20% after one year, compared with 63 percent of men achieving the same level of improvement (20%). Only 18 percent of women achieved levels of disease activity considered low on the Ankylosing Spondylitis Disease Activity Score.  26 percent of men achieved a low activity level of their AS (11).  

 

Those who take the drug hope to be among the 52%- 63% who achieve 20% improvement, but they must cope with the very serious side effects and risks that come with these drugs.

 

IL Inhibitors:  

IL stands for Interleukin.  

In January 2016 Cosentyx (Secukinumab), an IL-17 Inhibitor was approved for treating Ankylosing Spondylitis, as well as Psoriatic Arthritis.  It was the first drug of this class.

Cosentyx carries similar increased risks for infections and cancer as TNF Inhibitors.  In addition, it also is very concerning that in clinical trials Cosentyx has, in some cases, exasperated inflammatory bowel disease or brought on new cases of IBD.  The product label warns:  "Caution should be used when prescribing COSENTYX to patients with inflammatory bowel disease. Exacerbations, in some cases serious, occurred in COSENTYX treated patients during clinical trials in Plaque Psoriasis, Psoriatic Arthritis and Ankylosing Spondylitis. In addition, new onset inflammatory bowel disease cases occurred in clinical trials with COSENTYX."   

Again, since a significant percentage of patients with AS have IBD and/or bowel lesions, diagnosed or undiagnosed, symptomatic or asymptomatic, the risk is noteworthy for aggravating these symptoms or even causing the new onset of these symptoms. 

In 2016, the FDA approved Ustekinumab, sold under the brand name Stelera.  This drug is an IL-12 and IL-23 Inhibitor originally used to treat Psoriosis as well as Crohns Disease.  Recent studies have shown that patients with Crohns Disease as well as Spondyloarthritis symptoms had higher levels of Th17 cells, and that IL-23 triggers their activity.  The study suggests that patients who have both Crohns Disease AND Spondyloarthritis would benefit from a IL-23 Inhibitor (10.5).  However, not suprisingly, this drug does not come without serious risks.  These risks include serious infections (fungal, viral, bacterial), and cancers.  It also can cause a fatal condition called Posterior Leukoencephalopathy Syndrome (PLS), which affects your brain.  

Pain Medications -  

For mild to moderate pain relief, sometimes patients with AS take over-the-counter Acetaminophen (Tylenol or Extra Strength Tylenol).  When the pain of Ankylosing Spondylitis becomes more severe, despite medications, then often Narcotics, or Opioids, are prescribed.  If so, these painkillers are frequently taken on a regular basis, but sometimes a patient may choose to only use them just before engaging in an activity or activities that normally provoke their pain levels.   These drugs work by interacting with opioid receptors on nerve cells in the body and in the brain. Below are some of the most commonly prescribed painkillers used to manage AS:

 

OXYCODONE:  This narcotic is known as an opoid analgesic and it helps to relieve moderate to severe pain.  It works by changing how your brain responds to pain.  It comes available in an extended-release format which can be taken once every 12 hours.  This has the advantage of lasting throughout the entire night without the patient having to wake up and take a second dose in the middle of the night.  This is desirable since AS pain often is worse at night and in the early morning hours. The extended release Oxycodone is considered to be twice as potent as oral morphine.  In addition to the other side effects commonly associated with narcotics, Oxycodone also has been known to cause spinal cord infarction and damage to the brain due to prolonged suppressed breathing when overdosed.  Chronic use of Oxycodone often causes hormone imbalance, even when it is not overdosed.

 

OXYCODONE/ACETAMINOPHEN:  Also known as Percocet, Roxicet, Tylox, and Oxycet.  The addition of Acetaminophen increases the potency of Oxycodone. However, it also comes with a "black box" warning from the FDA.  This is because the drug has been associated with cases of acute liver failure, which has at times resulted in liver transplant and/or death. Most of these cases are associated with doses of Acetaminophen that exceed 4000 milligrams per day, or they involve more than one Acetaminophen-containing product.  It's very critical not to combine Oxycodone/Acetaminophen with any other products that contain Acetaminophen.   As mentioned above, in addition to the other side effects commonly associated with narcotics, the Oxycodone component of this medication also has been known to cause spinal cord infarction and damage to the brain due to prolonged suppressed breathing when overdosed.  Chronic use of Oxycodone often causes hormone imbalance, even when it is not overdosed.

HYDROCODONE/ACETAMINOPHEN:  Also known as Vicodin, Lortab, Lorcet, and Norco. This drug is prescribed even in the early stages of AS, but as the disease progresses, stronger narcotics may be required in order to control the pain.  This narcotic is a combination of Hydrocodone and Acetaminophen (Tylenol).  The addition of Acetaminophen increases the potency of Hydrocodone.  However, just like Oxycodone/Acetaminophen,  this medication also comes with a "black box" warning from the FDA regarding the addition of Acetaminophen.  This is because the drug has been associated with cases of acute liver failure, which has at times resulting in liver transplant and/or death.

TRAMADOL: Also called Ultram, ConZip.  It comes in the form of liquid, tablet, capsules, extended release, and even injections.  Interacts with many different drugs, include commonly prescribed muscle relaxers and others.

MORPHINE:   Also known as Duromorph, Infumorph, Arymo ER, MorphaBond ER, MS Contin, and Astramorph-PF. Morphine is also used to create Hydromorphone, Oxymorphone and Heroine.  This potent painkiller can be obtained in tablet form, although it is frequently used intravenously while in the hospital.  It comes in the form of extended release tablets as well.  Morphine was first isolated between 1803 and 1805 from the opium poppy by Friedrich Sertürner.  This is generally believed to be the first isolation of an active ingredient from a plant.   The drug was originally named morphium, after Morpheus, the Greek god of dreams, because the drug can make a person sleepy. Morphine is also known to have effects on the immune system that are still not fully understood.  It has been demonstrated that chronic morphine use leads to an increased production of interleukin-12 (IL-12), a cytokine responsible for promoting the proliferation and growth of T-cells (11).

OTHER PAIN MEDICATIONS:  Not all pain medications available on the market are listed here.  There are others, such as Fentanyl, Codeine, etc.  But there are some common features that all these opoids/narcotics share:

 

They all are controlled substances, only available by prescription and their use should be monitored by a physician. They all have the potential for dependency and addiction.    A number of patients who have been taking narcotics for chronic use no longer feel an ephoric effect from the medication, but still their body is physically dependent upon the medication in order to manage pain, and sudden discontinuation of the drug would cause serious side effects.  Due to the increasing number of individuals who live with pain on a daily basis, and the fact that they use and depend upon narcotics for pain management, some have referred to "an opioid epidemic" that exists in the United States.  Is it an opoid epidemic or a pain epidemic?  Perhaps both.  

But are opoids and narcotics the best way to manage that pain? Let's talk about some of the very serious concerns with opoid/narcotic use.  We already mentioned the real possibility of dependency, and this is when the drug is used normally, as prescribed by a doctor, not misused. In addition to this concern, Opoids often lead to hormone imbalances when they are taken chronically.  Other potential side effects may also include constipation, fainting, lightheadedness, dizziness, numbness (physically,mentally and emotionally), seizures, confusion, headaches (including migraines), drowsiness, vomiting, low blood sugar, circulatory collapse, abnormal or slowed heart rate, impaired thinking and physical abilities, shallow, depressed breathing (and even respiratory arrest), accidental overdose, and death.  Narcotics must be withdrawn slowly and under a doctor's supervision.  Suddenly stopping the medication can cause dangerous side effects.  Also very serious interactions can occur if they are mixed with alcohol.  

Many people who are trapped in the cycle of relying on opoids for pain relief do not like the fact that they need them, due to the very concerning side effects.  Yet, they believe there is no other choice.  Their pain is real!  They are not aware of any other options that can effectively manage the pain.  Therefore, the high price that opoids require (on health, quality of life, relationships, ability to function, etc) is a cost that they feel they have no option but to pay.  

 

As doctors who are concerned about the "opoid epidemic" become more and more reluctant to prescribe these pain relievers, patients who suffer with debilitating pain on a daily basis are frightened.  They can't imagine functioning without the help these drugs offer.  

Other options for managing pain besides narcotics and opoids, without the serious risks and side effects that come along with them, must be provided for patients suffering from Ankylosing Spondylitis (or any other painful condition, for that matter).  The good news is....there ARE other options!

 

Visit the page of our website which talks about a scientifically proven device for managing pain that is effective, non drug, non habit forming, without any known side effects and is providing patients with Ankylosing Spondylitis (as well as other conditions that cause chronic pain) SERIOUS relief.  Many AS sufferers find it life-changing to learn there are other options that can offer substantial pain relief besides opoids. Some patients, in an effort to avoid opoids, have just been suffering with the pain all of these years rather than risk the side effects of narcotics.  However, controlling pain is important, not only for quality of life, but also because it allows you to move, exercise, and maintain the range of motion and flexibility of your spine and joints.  Don't ignore the pain and inflammation.  On the other side of the coin, don't feel trapped into taking drugs that have undesirable effects and consequences.  Block pain at its source and escape the opoid prison!

 

 

 

Conclusion:

 

After considering the current conventional drug options available, what can be said?  The quality of life now for the average patient with Ankylosing Spondylisit is overall better than it was a couple of decades ago, but this comes at great cost....dependency on expensive drugs with life-threatening risks and serious side effects that will catch up eventually with the patient after long-term use, and sometimes even after short-term use.    Even with the medications, most patients are still suffering at different levels.  If they do receive relief, frequently it is temporary or short lived before the medications either stop working, or they begin manifesting concerning side effects that require the patient to discontinue and hop to another drug to begin the cycle again.  

 

Obviously the AS community would benefit from some safer alternatives that are more effective and have less risks involved.  For this reason, many have turned to complimentary treatment modes.  Many patients have found that by implementing complimentary therapies, they require a much lower dosage of conventional medicines than they needed before, with the same, or better outcome.  By lowering their dosages, they effectively lower the risks of undesirable side effects.  You might be surprised to learn that many have even been able to successfully manage their symptoms entirely by using these complimentary therapies,  and have weaned themselves off of the drugs, under a Physician's guidance (do not suddenly stop taking any medication without talking to a Doctor first).

Why not explore some of these complimentary approaches and the science behind them?  Education is empowering. 

 

 

 

 

 

 

REFERENCES:

1. Mielants H, The evolution of spondyloarthropathies in relation to gut histology. II. Histological aspects, J Rheumatol. 1995 Dec;22(12):2273-8.

2. Mielants H, Veys EM, Cuvelier C, de Vos M. Ileocolonoscopic findings in seronegative spondylarthropathies. Br J Rheumatol. 1988;27(Suppl 2):95–105.

3.   Cuvelier C, Barbatis C, Mielants H, De Vos M, Roels H, et al. Histopathology of intestinal inflammation related to reactive arthritis. Gut. 1987;28:394–401.

4.  Leirisalo-Repo M, Turunen U, Stenman S, Helenius P, Seppala K. High frequency of silent inflammatory bowel disease in spondylarthropathy. Arthritis Rheum. 1994;37:23–31. 

5.  Shelagh M. Szabo, Increased Risk of Cardiovascular and Cerebrovascular Diseases in Individuals With Ankylosing Spondylitis, ARTHRITIS & RHEUMATISM Vol. 63, No. 11, November 2011, pp 3294–3304 DOI 10.1002/art.30581.

6.  Mäki-Ikola Nissilä MLehtinen KLeirisalo-Repo MToivanen PGranfors K, Antibodies to Klebsiella pneumoniae, Escherichia coli and Proteus mirabilis in the sera of patients with axial and peripheral form of ankylosing spondylitis, Br J Rheumatol, 1995 May;34(5):413-7.

 

7.  Nissilä M1, Lahesmaa RLeirisalo-Repo MLehtinen KToivanen PGranfors K, Antibodies to Klebsiella pneumoniae, Escherichia coli, and Proteus mirabilis in ankylosing spondylitis: effect of sulfasalazine treatment, J Rheumatol. 1994 Nov;21(11):2082-7.

8.  M. NISSILA, K. LEHTINEN, M. LEIRISALO-REPO, R. LUUKKAINEN, 0. MUTRU, and U. YLI-KERTTULA, Sulfasalazine in the treatment of Ankylosing Spondylitis, Arthritis and Rheumatology Volume 31, Issue 9, September 1988 
 Pages 1111–1116, DOI: 10.1002/art.1780310905.

9.  Perez-Alvarez, Robertoa; Pérez-de-Lis, Martaa; Ramos-Casals, Manuel, Biologics-Induced Autoimmune Diseases, Current Opinion in Rheumatology, January 2013, Volume 25 Issue 1 pp 56-64, DOI: 10.1097/BOR.0b013e32835b1366.

10.  I.-H. Song,1 F. Heldmann,2 M. Rudwaleit,1 J. Listing,3 H. Appel,1 J. Braun,2 and J. Sieper, Different Response to Rituximab in Tumor Necrosis Factor Blocker–Naive Patients With Active Ankylosing Spondylitis and in Patients in Whom Tumor Necrosis Factor Blockers Have Failed, ARTHRITIS & RHEUMATISM Vol. 62, No. 5, May 2010, pp 1290–1297 DOI 10.1002/art.27383.

10.5  IgA-coated E. coli enriched in Crohn’s disease spondyloarthritis promote T H 17-dependent inflammation. Science Translational Medicine, 2017; 9 (376): eaaf9655 DOI: 10.1126/scitranslmed.aaf9655

11.  The Journal of Rheumatology February 2018, jrheum.170166; DOI: https://doi.org/10.3899/jrheum.170166

12.  Messmer D, Hatsukari I, Hitosugi N, Schmidt-Wolf IG, Singhal PC (2006). "Morphine reciprocally regulates IL-10 and IL-12 production by monocyte-derived human dendritic cells and enhances T cell activation". Mol. Med. 12 (11–12): 284–90. doi:10.2119/2006-00043.MessmerPMC 1829197 . PMID 17380193.

Complimentary Treatments For Ankylosing Spondylitis

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"The first time I put the device on my lower back to see if it would help my Ankylosing Spondylitis pain, I could hardly believe the results. Within 20 minutes I felt a noticeable reduction in pain levels that kept growing until my pain was barely noticeable! The science behind the technology led me to try it, but it was the results that hooked me. Now, years later, it still is my first choice for pain relief!"

                                     - Amy From Texas U.S.A.