Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs reduce pain when taken at a low dose, and relieve inflammation when taken at a higher dose. NSAIDs such as ASA (Aspirin, Anacin, etc.) and ibuprofen (Motrin IB, Advil, etc.) can be purchased without a prescription. Examples of other NSAIDs that require a prescription include Naprosyn, Relafen, Indocid, Voltaren, Feldene, and Clinoril. The various NSAIDs and Aspirin®, if taken in full doses, usually have the same levels of anti-inflammatory effect. However, different individuals may experience greater relief from one medication than another. Taking more than one NSAID at a time increases the possibility of side effects, particularly stomach problems such as heartburn, ulcers and bleeding. People taking these medications should consider taking something to protect the stomach, such as misoprostol (Cytotec).
Disease-modifying anti-rheumatic drugs (DMARDs)
Disease modifying anti-rheumatic drugs (DMARDs) are often prescribed to relieve severe symptoms of ankylosing spondylitis. These medications are designed to prevent AS from getting worse, but do not reverse permanent joint damage. It will usually take several months for DMARDs to make a noticeable improvement in the inflammation.
The most common DMARDs are methotrexate and sulfasalazine. DMARDs are often given along with other medications such as NSAIDs. Common side effects of DMARDs are mouth sores, diarrhea and nausea. These drugs may have effects on pain or swelling in hands or feet but have not been shown to be effective in inflammation in the spine. More serious side effects, monitored through regular blood and urine tests, include liver damage, and excessive lowering of white blood cell count (increasing susceptibility to certain infections), and platelet count (affecting blood clotting).
Corticosteroids
For severe pain and inflammation, doctors can inject a powerful anti-inflammatory drug, called a corticosteroid, directly into the affected joint. Cortisone is a steroid that reduces inflammation and swelling. It is a hormone naturally produced by the body. Corticosteroids are man-made drugs that closely resemble cortisone. An injection can provide almost immediate relief for a tender, swollen, and inflamed joint. However, this treatment can only be used periodically because excess corticosteroids can weaken the cartilage and bone.
If your eyes are affected, cortisone eye drops may also be prescribed.
Biologic Response Modifiers “Biologics”
The newest medical option for treating AS is a class of drugs called biological response modifiers (BRMs), or biologics. Biologics are DMARDs that are made up of genetically modified proteins. They work by blocking specific parts of the immune system, called cytokines, which play a role in ankylosing spondylitis. The most commonly used biologics block one of two important cytokines, either tumor necrosis factor (TNF) or interleukin-1 (IL-1). Biologics are often used to treat rheumatoid arthritis, and recently have been shown to have the potential to slow or even halt the progression of AS in some people. Unlike the other DMARDs, they have been shown to effectively treat the spinal arthritis also associated with AS, as well as the arthritis of the joints of the hands or feet. These drugs work quickly to ease inflammation and can be used in combination with other medications, such as DMARDs.
Depending on the biologic prescribed, they are either given by injection at home or by an intravenous infusion at a clinic. Side effects occasionally seen with these medications include mild skin reactions at the injection site, headaches or dizziness, colds or sinus infections, and nausea or diarrhea. Your doctor will discuss all of the other side effects of these medications before he or she prescribes them.
Currently, Enbrel, Humira, Remicade and Simponi have received approval for the indication of ankylosing spondylitis, specifically. Your physician will explain the differences between these medications should he or she prescribe a biologic for AS.
What else should I know about biologics?
Precaution
Biologics work by suppressing your immune system which can make it slightly harder for you to fight off infections. Please inform your doctor if you are prone to frequent infections. It is advisable to stop your medication and call your doctor if you develop a fever or if you have or think you have an infection. Before starting biologics, your doctor should check for other infections, such as tuberculosis.
Cost
Biologic treatments are costly, and can range anywhere from $15,000 to $25,000 per year. Depending on the type of insurance coverage you have, treatments may be fully covered or you may be required to share the cost. Generally, provincial plans or private insurance companies will require patients to attempt conventional treatments before they will cover biologics.
The medication that is working for you will be the one that best controls the inflammation and pain. Realize that in most instances it does not result in the pain going away totally. If taking the medication results in a 75% reduction of pain that may be a good result. Work with your rheumatologist to find something that helps most.
A word about Medication Safety
The need to effectively monitor new drugs once they have been approved and introduced into the market has been a key advocacy issue for The Arthritis Societyfor several years. This advocacy helps to ensure that unfavorable side effects are reported, documented, and addressed. For regular updates on medications availablein Canada, visit
www.arthritis.ca/tips/medications.
All medications have potential side effects whether they are taken by themselves or in combination with other herbal, over-the-counter and prescription medications. It is therefore important for patients to discuss the benefits and potential side effects of alltheir medications with their doctor.
Health Canada’s Marketed Health Products Directorate (MHPD) has recently developed a new website, named MedEffect. MedEffect’s goal is to provide centralized access to new safety information about health products in an easy to find, easy to remember location. It also aims to make it as simple and efficient as possible for health professionals and consumers to complete and submit adverse reaction reports. Finally, it helps to build awareness about the importance of submitting adverse reaction reports to identify and communicate potential risks associated with certain drugs or health products. To find out more, visit:
www.healthcanada.gc.ca/medeffect orcall toll-free 1.866.234.2345.
Exercise
Exercise is one of the most important ways to successfully manage AS because it keeps joints moving and reduces pain. It will also help reduce stiffness and strengthen the muscles surrounding joints. Exercise should be done for three major reasons:
1.to maintain or restore spinal mobility,
2.to maintain or improve posture,
3.to maintain chest expansion.
A physical therapist can teach you a program of range of motion exercises for your neck, mid back and low back which should be done daily if you have AS. You won't necessarily do them all daily, but will do some exercise each day to maintain your mobility. You probably should focus with range of motion exercises on particular areas that are troublesome. For example, if your neck is painful and prone to stiffness you should be doing gentle mobility exercises to maintain movement of your neck.
As there is a tendency, because of AS, to stoop forward and to get stiff in this position, strengthening exercises should be done to increase the muscle power of those muscles that keep you upright and erect - the extensors or back muscles. This is contrary to the type of exercises often given to people with the more common back injury. Gentle stretching exercises are important to prevent stiffness and postural changes.
To maintain your chest expansion and rib mobility your physical therapist may also instruct you in breathing exercises.
Choose a time of the day for exercising that works for you. Most people with AS are stiff in the morning so this is probably not a good time to do your exercises. If you hurt take a warm bath prior to exercising.
Generally low impact sports like cycling or swimming are well tolerated and contribute to overall fitness and flexibility.
Heat
Heat applied to an arthritic area can help relax aching muscles, and reduce pain and soreness. Taking a hot shower is a great way to help reduce pain and stiffness in the morning. Heat should not be applied to an already inflamed joint however to avoid making symptoms worse.
Protect Your Joints
Protecting your joints means using them in ways that avoid excess mechanical stress from daily tasks. Benefits include less pain and greater ease in doing tasks. Three main techniques to protect your joints include:
Pacing, by alternating heavy or repeated tasks with easier tasks or breaks, reduces the stress on painful joints and allows weakened muscles to rest. Pacing and planning also provide you with ways to deal with fatigue.
Positioning joints wisely helps you use them in ways that avoid extra stress. Use larger, stronger joints to carry loads. For example, use a shoulder bag instead of a hand-held one. Also, avoid keeping the same position for a long period of time.
Using assistive devices, such as canes, raised chairs, grip and reaching aids, can help make daily tasks easier. Using grab bars and shower seats in the bathroom can help you to conserve energy and avoid falls.
If you have AS it is very important that you sleep on a firm supportive surface to maintain good spinal alignment for the one third of your day you spend in bed. A saggy mattress or waterbed can permit you to sleep in positions that, over time, might lead to posture that is stooped. Your neck should be supported in as good a position as can be achieved with special neck supports or pillows.
Also be aware of your posture during the day. Pay attention to how you are standing. Look at your habitual work postures. Do you sit upright? If you work at a computer is the monitor on your desk high enough so you are not looking downward? Modify your working positions to better maintain a good posture. Do your best to keep your back straight and avoid the tendency to slump forward, even if it does feel more comfortable. Deal with your pain with medication, exercise, rest and heat but maintain a good posture.
Relaxation
Developing good relaxation and coping skills can give you a greater feeling of control over your arthritis and a more positive outlook. Try deep breathing exercises. Listen to music or relaxation tapes. Meditate or pray. Another way to relax is to imagine, or visualize a pleasant activity such as lying on the beach, or sitting in front of a fireplace.
Surgery
People with severe, advanced AS may require surgery for badly damaged joints. Surgery usually involves replacing a joint with an artificial joint. This is most commonly used for the end stage of damage to the hip joints, called a total hip joint replacement. Benefits include less pain, better movement and restored function.
Cochrane Reviews of Treatments
The Cochrane Musculoskeletal Review Group (CMSG) is a specialized group of researchers and consumer representatives that belong to the Cochrane Collaboration, an international not-for-profit organization that encourages informed decisions about health care by preparing, maintaining and promoting reviews of the effects of various health care treatments.
CMSG members review the best available literature to determine the best evidence to support specific arthritis treatments. They explore the evidence for and against the effectiveness and appropriateness of treatments (medications, surgery, education, etc) in specific circumstances. The results are medical reviews that are then included in The Cochrane Library and made available to health professionals around the world.
For members of the public who also want to be informed about the evidence concerning health care practices and decisions in their lives, the Cochrane Musculosketal Review Group have summarized their reviews into consumer fact sheets. For the Cochrane consumer reviews related to ankylosing spondylitis, visit
www.arthritis.ca/cochrane.
Outcomes
While the course of AS varies, most people do well and continue to live normal but sometime modified lives.
Those with very heavy jobs requiring a lot of bending and lifting may have to consider an alternative.
Additional Tips for Living Well
Along with the physical symptoms of arthritis, many people experience feelings of helplessness and depression. Learning daily living strategies to manage your arthritis gives you a greater feeling of control and a more positive outlook. To get the best results, people affected by arthritis need to form close ties with their doctors and therapists, and become full partners in their treatment. From our perspective, it's all part of 'living well with arthritis.' There are several resources you can use in finding out how best to manage your own arthritis. Here are a few:
The Arthritis Self-Management Program (ASMP) is a unique self-help program offered by The Arthritis Society to help you better control and manage your arthritis.
The Open Forum within this Web site is an opportunity to discuss and share information with other visitors - people who, through their own experiences, may be able to offer some useful insights.
Of course, there are many other valuable resources for people with arthritis. If you're unclear about where to look for help, be sure to call The Arthritis Society at 1.800.321.1433.
Болезнь бехтерева или Ankylosing Spondylitis.