ReportWire

Tag: axial spondyloarthritis

  • What’s Next for Ankylosing Spondylitis Treatment?

    What’s Next for Ankylosing Spondylitis Treatment?

    By Abhijeet Danve, MD, as told to Hallie Levine

    I have studied and treated ankylosing spondylitis (AS) for almost 10 years. It’s a form of axial spondyloarthritis (axSpA). That’s a type of inflammatory arthritis that primarily affects the spine and the sacroiliac (SI) joints that connect the lower spine to the pelvis. In its early stages, it’s called non-radiographic axSpA because its damage doesn’t usually show up yet on an X-ray. But in its late stage, when it does become apparent, it’s known as ankylosing spondylitis (AS).

    Unfortunately, many people with AS go undiagnosed for 8-11 years. Up to 5% of patients with chronic back pain actually have AS or its earlier form, axSpA. But if you complain of back pain to your doctor, they usually just send you off for an X-ray of your lumbar spine, or lower back. This won’t help them spot the condition since the first signs are in your sacroiliac joints. And it can take up to 10 years for these changes to show up on conventional X-rays. There’s also a lack of awareness about this condition among doctors that treat back pain. As a result, we sometimes lose that window of opportunity to identify and treat people with AS at earlier stages.

    Quicker Diagnosis

    Thankfully, new guidelines were released about 10 years ago that allow us doctors to diagnose patients sooner. It’s now recommended that anyone with suspect axSpA and inconclusive X-rays have an MRI of their sacroiliac joints, too. It’s important to ask your doctor for a referral to a rheumatologist if you have chronic back pain that lasts for more than 3 months, starts gradually before the age of 45, is worse with rest, and improves with exercise. This is a specialist specifically trained to diagnose and treat inflammatory diseases that affect your joints and bones, like axSpA. They’ll screen you for other symptoms associated with this condition, including back pain that wakes you up in the middle of the night, heel or foot pain (plantar fasciitis), or inflammation in other parts of your body like your eyes (called iritis or uveitis), skin psoriasis, and intestinal inflammation (called Crohn’s disease). They can also order a blood test to screen for HLA-B27, a gene that raises your chances of getting axSpA. Remember, the earlier you get diagnosed, the more quickly you’ll be able to start treatments that can help improve symptoms, ease inflammation, and possibly prevent permanent joint damage.

    Notable Developments

    Thankfully, we now have many excellent drugs available to treat both axSpA and AS. Almost half of all people respond well to nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and indomethacin. But if you don’t, there’s a whole class of drugs you can try known as tumor necrosis factor (TNF) blockers. When you have either condition, your body makes too many proteins called cytokines, which ramp up inflammation throughout your body. Over time, this is what causes joint and bone damage. The TNF blockers, given as injections, stop some of these cytokines.

    For a long time, these were the only drugs available. But in the last several years, the FDA approved two new injectable drugs: ixekizumab (Taltz) and secukinumab (Cosentyx). They both block another type of inflammatory cytokine called interleukin-17, or IL-17. Normally, IL-17 helps your body defend itself against infections. But too much of it can cause joint inflammation, bone erosion, and bone fusion. These drugs target different cytokines than the TNF inhibitors, so the hope is that they can help those who haven’t gotten help from the TNF inhibitors.

    Janus kinase (JAK) inhibitors are the newest class of drugs approved by the FDA to treat ankylosing spondylitis. The two JAK inhibitors approved for this use are tofacitinib and upadacitinib. A third is being researched in hopes it’ll be available in the future.These are medications traditionally used to treat rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis. They inhibit several cytokines key to the progression of ankylosing spondylitis.  Like biologics, they work on your immune system, but they’re different than biologics too. They suppress various targets in your body to prevent overactive immune system responses before they start. JAK inhibitors are more convenient than biologics, since you can take them orally.

     [TMA1]https://spondylitis.org/research-new/new-treatment-approved-for-ankylosing-spondylitis-fda-oks-first-jak-inhibitor/

     [TMA2]https://creakyjoints.org/about-arthritis/axial-spondyloarthritis/axspa-treatment/fda-approves-upadacitinib-for-anklosing-spondylitis/There are studies underway to develop even more. There’s a new class of oral drugs, janus kinase (JAK) inhibitors, that show a lot of promise. These inhibitors block specific enzymes (JAK1, JAK2, and JAK3) that signal your cells to make more inflammation. One study found that people who took a JAK inhibitor for just over 3 months were twice as likely to have a strong response as those who took a placebo, or fake pill. Two drugs, tofacitinib and upadacitinib, are in clinical trials. We should know within the next year whether they get FDA approved.

    There’s another class of medications called interleukin-23 inhibitors, like guselkumab and risankizumab, that are just as exciting. These target a cytokine known as interleukin-23 (IL-23) that also signals your cells to make more of another inflammatory cytokine, interleukin-17, or IL-17. When IL-23 is blocked, it stops the production of IL-17. This helps ease inflammation in your joints and lessens the chances of permanent damage.

    The Importance of Lifestyle Changes

    While our treatments get better and better, I tell my patients they aren’t enough. Lifestyle is key when it comes to controlling symptoms and improving mobility. Daily range of motion and stretching exercises are particularly important. These improve flexibility and reduce stiffness, swelling, and pain. You’ll also need to exercise regularly, which includes strength and balance activities.  

    I also stress to my patients that if they smoke, they need to quit. Smoking is bad for everyone’s health, but it’s particularly bad for people with inflammatory diseases like axSpA and AS. Research shows it can worsen symptoms like pain and mobility problems. People with axSpA and AS are also more likely to have depression or anxiety. It’s important to seek help, whether it’s through support groups or talk therapy. This can help you manage living with the disease.

    Source link

  • Treating Ankylosing Spondylitis With Biologics

    Treating Ankylosing Spondylitis With Biologics

    Your doctor may prescribe certain treatments, like nonsteroidal anti-inflammatory drugs and physical therapy, to help your ankylosing spondylitis. But everyone is different: What works for someone else might not work for you. If this happens, your doctor will most likely recommend that you try a new class of drugs known as biologics.

    “These are amazing drugs that have really revolutionized how we treat this disease,” says Yale Medicine rheumatologist Deborah Desir, MD.

    Though they won’t magically cure your ankylosing spondylitis, they can help slow the disease’s progression and make symptoms more manageable.

    How Do Biologics Work?

    Biologics stop the damaging inflammation that happens with ankylosing spondylitis.

    “They’re genetically engineered proteins that target cytokines, specific molecules in your immune system,” says Lianne Gensler, MD, director of the University of California San Francisco’s Ankylosing Spondylitis Clinic.

    Cytokines activate inflammation throughout your body, which keeps your immune system on its toes to fight off invaders. But if they go into overdrive, they can trigger inflammatory diseases such as ankylosing spondylitis.

    There are two main classes of biologics used to treat ankylosing spondylitis:

    Tumor necrosis factor alpha (TNF-α) inhibitors. These were the first approved in 2003. They work not only to ease joint inflammation, but related inflammation in the gut and eyes as well. There are five approved for ankylosing spondylitis:

    • Adalimumab (Humira)
    • Certolizumab (Cimzia)
    • Entanercept (Enbrel)
    • Golimumab (Simponi)
    • Infliximab (Remicade)

    IL-17 inhibitors. Two are FDA-approved for ankylosing spondylitis: ixekizumab (Taltz) and secukinumab (Cosentyx). They target different cytokines than the TNF inhibitors. They’re often used in people whose ankylosing spondylitis didn’t respond to several of the TNF medications.

    Who Should Take Biologics?

    While biologics are very effective, they’re not for everyone.

    “These drugs are very powerful, but they also suppress the immune system, which means you’re more vulnerable to infection,” Gensler says. Because of this, most doctors hold off using them right away.

    When you’re newly diagnosed with ankylosis spondylitis, your doctor will most likely start you on a course of nonsteroidal anti-inflammatory drugs (NSAIDS). These include over-the-counter versions such as ibuprofen, as well as prescription-strength drugs like celecoxib (Celebrex).

    “These drugs are the most common ones we use, and for good reason: a huge percentage of patients are able to get control of their symptoms on them,” Desir says.

    They’ll also prescribe physical therapy to help ward off the “frozen” spine and general stiffness that can occur with ankylosis spondylitis.

    The downside of NSAIDs is that to stay symptom-free, most people need very high doses. Over time, this can lead to side effects such as stomach bleeding and higher risk of heart attack or stroke.

    “We’re most worried about these side effects in older adults, since they are the ones who are already at risk for these diseases. But for a younger patient in their 20s or 30s newly diagnosed with the condition, that’s much less of a concern,” Gensler says. “We don’t have long-term safety data on biologics yet beyond about 2 decades, so it’s still unknown what the effects of these drugs would be on patients who are on them for most of their lives. That’s why we’d prefer to start with an NSAID, and then escalate if need be.”

    In general, Gensler says you should consider a biologic if:

    • You’ve tried a course of NSAIDs and physical therapy for a few weeks and are still bothered by symptoms.
    • Your X-rays already show that you have a lot of damage to your sacroiliac joints, the joints that connect your spine to your pelvic bone.
    • You’ve already lived with ankylosis spondylitis for a long time.

    It can sometimes take up to 10 years for people to be diagnosed with this condition.

    “Sometimes patients come in for the very first visit in extreme pain and very disabled, and they say that their quality of life is terrible and they’d do anything to get it back to where they can function again,” Gensler says.

    What Should I Expect When I Take a Biologic?

    If you and your doctor agree biologics are the next step, they’ll test you for tuberculous first.

    “Some people have what’s known as latent TB, where the bacteria live silently in their lungs,” Desir says. “Since these drugs suppress your immune system, the TB can ‘wake up’ and cause an actual infection.”

    All biologic treatments leave you more prone to infection, especially upper respiratory infections such as colds, flu, or COVID-19. To stay healthy, you should:

    • Wash your hands often
    • Avoid or wear a mask in crowded areas, enclosed spaces, public transportation, and childcare facilities
    • Keep up to date on all your vaccines, including the flu and COVID-19 vaccines.

    Some biologics are given at home via self-injection, and others are given through an IV in your doctor’s office. You may notice some pain, redness, and swelling. You can use antihistamines and an over-the-counter pain reliver such as acetaminophen to treat discomfort.

    If you’re on the fence about trying a biologic, Gensler suggests giving it a 3-month trial.

    “I stress to (people) that this does not have to be a lifetime commitment. They can always go off of the biologic and return to their original medications,” she says. “But oftentimes, after a few months, people are shocked at how much better they feel. They’ve suffered for so long they’ve just accepted their symptoms as normal. But thanks to biologics, it doesn’t have to be that way anymore.”

    Source link