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Ankylosing Spondylitis

Pain, General | March 8, 2016 | Author: The Super Pharmacist

general, Pain

Ankylosing Spondylitis

Ankylosing spondylitis is a condition that affects the spine as well as the joints between this structure and the pelvis. It is a chronic inflammation of these bones. Ankylosing spondylitis may be associated with new bone growth in and between spinal joints, resulting in their fusion into one structure over time. This is known as ankylosis, or the amalgamation of several bones into one. Ankylosis of the spine may result in characteristic deformities, including 'bamboo spine'. It is associated with the release of 'pro-inflammatory' molecules such as TNFalpha.

Symptoms

The symptoms of ankylosing spondylitis may include:

  • Spinal deformity, which may often take the form of kyphosis, or the curving over of the spine
  • Back pain that persists for three months or more
  • Increased inactivity or debility. This may be influenced by age, the duration of the condition, and the extent of spinal deformity.

Associated Diseases

Some research indicates that ankylosing spondylitis may be associated with the increased risk of hip disease. A study of 265 patients found that sacroiliitis (or the inflammation of joints between the spine and pelvis), delays in diagnosis, early onset and functional status in ankylosing spondylitis were associated with severe hip disease.

Ankylosing spondylitis may be associated with a slight increase in the risk of cardiovascular disorders. A study comparing forty patients to an equal number of healthy controls without cardiovascular risk factors found that the risk markers carotid intima-media thickness (CIMT) and epicardial adipose tissue thickness (EAT), were significantly greater in the patient group in comparison to controls.

Other conditions such as uveitis, inflammatory bowel disease and psoriasis are prevalent among patients with ankylosing spondylitis.

Causes of Ankylosing spondylitis

The exact cause of ankylosing spondylitis has not been defined. It is associated with some risk factors, or variables that influence the probability of the development of this condition.

These may include:

Treatment and management of Ankylosing SpondylitisImmune system activity: A study including 55 patients with mild to severe ankylosing spondylitis and 20 matched healthy individuals found differences in the proportions of various immune-system cells between these groups.

The patients had significantly increased numbers of T helper cells (Th1 and Th17 subtypes) compared to the controls. This may explain the presence of pro-inflammatory molecules seen in the condition.

Ankylosing spondylitis has also been found to be associated with other components of the immune system, including the major histocompatibility complex (MHC) and the 'master immune control' molecule NFkappaB. There is also some evidence that suggests that ankylosing spondylitis may be an autoimmune condition.
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Genetic factors: The gene HLA-B27 is thought to play a role in the development of ankylosing spondylitis. The development of this condition is also associated with a family history of similar conditions (i.e. arthritis of the spine).

Trauma: Ankylosing spondylitis may be associated with musculoskeletal trauma in some cases.

Infection or inflammation in other tissues: A study of 58 children with ankylosing spondylitis found that the onset of the condition was associated with fever, dysentery or urethritis in up to 41% of cases. A history of conditions such as conjunctivitis and iritis was also associated with the condition.

Male gender: The same study found that the number of boys with ankylosing spondylitis was double the number of girls with the condition. Studies in other populations have found that the ratio of male to female patients is closer to 4:1.

Vitamin D deficiency: A review of eight trials including 533 patients and 478 matched healthy controls indicated that increased serum vitamin D was significantly associated with the decreased risk of ankylosing spondylitis.

Diagnosis of Ankylosing SpondylitisAnkylosing Spondylitis

  • This condition is typically diagnosed through visualisation of the spine using radiography. 
  • Inflammation of the spine may also be detected with magnetic resonance imaging (MRI).
  • Spinal joint fusion may be detected using computerised tomography (CT scan).
  • The progression and severity of this condition is measured using specific assessment tools such as the Bath Ankylosing Spondylitis Disease Activity Index.

 

Treatment and management of Ankylosing Spondylitis

There are several treatment options for ankylosing spondylitis, including:

Antibody therapy

Infliximab is an anti-TNFalpha antibody, or a protein that locates and binds to TNFalpha to prevent its function in the increase of inflammation in conditions such as ankylosing spondylitis. A pilot study administered 5mg/kg infliximab to eleven patients with active ankylosing spondylitis at three points, two or four weeks apart. Nine patients experienced an improvement in pain scores, functional status and activity levels as a result. This lasted for six weeks after the last administration for eight patients. This indicates the potential of TNFalpha antibody therapy in the treatment of ankylosing spondylitis. However, one patient in this study withdrew due to adverse effects after the first treatment session.

Another anti-TNFalpha antibody, adalimumab, is also currently in use as a treatment for ankylosing spondylitis. This is associated with significant responses and improvements in disease rating scales.

Other anti-TNFalpha antibodies used in the treatment of this condition include:

  • Etanercept
  • Golimumab
  • Certolizumab

Exercise

Treatment and management of Ankylosing SpondylitisConditioning and training may have beneficial effects in conditions such as ankylosing spondylitis, by strengthening the muscles, ligaments and tendons that surround and support the spine. This may lead to improvements in functional status and reductions in pain. A review of 18 high-quality studies on exercise in ankylosing spondylitis management found significant positive effects on disease intensity, patient mobility and functional status compared to normal activity.

NSAIDs

Non-steroidal anti-inflammatory drugs are associated with the significant reduction of inflammation, and are often used in the treatment of ankylosing spondylitis. They may be used continuously or as needed in response to pain onset. A review of studies on NSAIDs in ankylosing spondylitis treatment found that there was no significant difference in symptom control between these strategies. Four studies showed a decrease in disease progression as a result of continuous NSAID therapy. NSAIDs are associated with increased risks of adverse effects with regular intake. However, a study of ankylosing spondylitis treatment with celecoxib found no significant differences between the incidence of side effects between patients who used the drug continuously and those who used it at need.

Surgery

Osteotomies are surgical procedures to correct severe spinal deformity, if necessary. Osteotomy using up-to-date techniques and applications (e.g. pedicle subtraction) may result in significant correction of kyphosis and the restoration of normal activities such as walking fully upright. Other forms of surgery required in severe advanced ankylosing spondylitis may include total hip replacement.
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References:

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