Ankylosing Spondylitis is easy to treat. Or is it?

Like most rheumatologists in Australia, I reckon Ankylosing Spondylitis is easy to treat.

Most respond to anti-inflammatory medications, either the NSAIDs or Cox-2 inhibitors. If one of these doesn’t work, there are plenty of others to try instead.

Add to that plenty of exercise. Preferably low impact.

And some rheumatologists like yours truly even advocate some nutrition measures to help (consider anti-inflammatory eating) and of course the usual lifestyle measures of stopping smoking and losing weight.

Easy.

Many respond.

And for those who don’t, at least in a relatively rich country like Australia, and as long as they meet the government-set criteria, we can use the TNF-inhibitor medications (trade names: Enbrel, Humira, Remicade, Simponi & Cimzia).

And rheumatologists as a group would expect these to work, and to work very well and quickly. At least 80 - 90% of the patients I place on these medications do really well so it’s an expectation that there’ll be a happy and grateful patient after a couple of injections.

Only, some patients don’t seem so happy. And understandably, not so grateful. And then it becomes not-so-easy. 

While I think it’s the minority, there are clearly patients with ankylosing spondylitis with persistent pain and stiffness despite being on “the best” we have.

I’ve had a number of patients in this difficult scenario in recent times and the thought process I then go through includes:

• They’ve typically presented late (i.e. the diagnosis was delayed by many years), and there is significant restriction and deformity/damage present. Stuff that is irreversible and which causes chronic symptoms. TNF-inhibitor medications cannot help this.

• They’ve typically presented late, and have already been subjected to a number of events and illnesses leading the patients to develop a centralised pain syndrome, such as fibromyalgia. TNF-inhibitor medications do not help this.

• Rethink the diagnosis. Did we make a mistake? Is another diagnosis missed? 

• Perhaps the patient is truly TNF-inhibitor resistant? This is a problem as we don’t currently have another class of biologic agents subsidised by our health system for ankylosing spondylitis but we eagerly anticipate the IL-17 inhibitors, eg Secukinumab.

As a group, ankylosing spondylitis can be very satisfying for the rheumatologist to treat.

Most respond and through relatively simple measures, we can make important improvements in quality of life.

For some, it is not quite so easy. I’m recognising this more.

Feel free to share your experience.