Ankylosing Spondylitis and axial Spondyloarthropathy

What is AS?

AS causes persistent inflammation in the spine and sacroiliac joints that can lead to loss of spine and neck movement over many years. The stiffening is due to small bone spurs forming at entheses, where there has been inflammation before (enthesitis; see Patient Information on ‘Spondyloarthritis’). The bone spurs in the spine are called syndesmophytes. If severe these syndesmophytes link vertebral bone to each other to cause reduced spine movement (‘ankylosis’).

What is aSpA?

aSpA is a relatively new term for improving the definition of AS and is useful for formalizing the description of the early, and/or less severe, forms of AS.

How are aSpA/AS diagnosed?

Doctors are alerted to aSpA by the presence of Inflammatory Back Pain (IBP; see Patient Information on ‘Spondyloarthritis’). An assessment by a Rheumatologist, then MRI of spine and/or sacroiliac joints and some blood tests (including checking HLA B27) completes the process to make a diagnosis.

The symptoms of aSpA/AS

The hallmark symptoms are pain and stiffness in the spine. Fatigue is common. Pains can come and go particularly in tendons and ligaments around the lower back, pelvis and sometimes in the legs (see ‘Enthesitis’ in Patient Information on ‘Spondyloarthritis’).

Who gets it?

aSpA/AS is a consequence of an abnormal immune system, which is linked to carrying a gene called HLA B27. About one in ten Caucasians have this gene and are at increased risk of getting AS; however, only about one in 15 people with the gene develop AS, so the majority of people who carry the gene HLA B27 do not get AS. The condition often starts in the 20s or 30s.

This is a long-term condition. What does the future hold?

There is a high degree of variability in how aSpA changes over time - in pain, stiffness and fatigue - but also in what degree of ankylosis (permanent stiffening of the spine can occur). For most people the symptoms can come and go so there can be troublesome periods but also long periods where the symptoms settle and are not too bothersome. Discuss with your Rheumatologist what your prospects and aims should/can be for work and lifestyle and establish a plan of treatment to achieve realistic goals.

What treatments are there?

Regular exercises for the spine; see: Rheumatologists frequently recommend non-steroidal anti-inflammatory painkillers (NSAIDs). For people with severe spinal (AS) symptoms, where NSAIDs don’t help sufficiently, then TNFi treatments are used (Biologics; see Patient Information Leaflet on ‘Biologic Drugs’). Where there is peripheral arthritis (or severe/frequent) enthesitis also immunosuppressant drugs can be used (e.g. sulfasalazine, methotrexate; see Patient Information on DMARDs).

Enthesitis can also be treated with cortisone injection. Very occasionally steroid treatment is used (either as a ‘one-off’ general injection or as a short course of tablets – prednisolone; see Patient Information on ‘Steroids’). There may be a useful beneficial effect on spinal symptoms from repeated intravenous infusions of Pamidronate (e.g. monthly for 3-6 months). Whether this works may depend on the number and severity of spinal osteitis lesions there are (areas of bone inflammation as shown by spine MRI scan).

What things can I do if I have aSpA or AS?

There’s no evidence that any specific diet affects aSpA or AS though there has been some research on reducing complex carbohydrates (‘low starch’). Please discuss this with your Rheumatologist. Extra painkillers (e.g. gabapentin or pregablin) may be of use especially if NSAIDs can’t be taken. Smoking has been shown to make aSpA/AS worse and so it should be stopped. If there is foot arthritis/enthesitis then seeing a podiatrist may be sensible as foot orthoses may help.

Useful links

See also Patient Information on ‘Spondyloarthritis’