Ankylosing spondylitis - Treatment 

Treating ankylosing spondylitis 

Back stretches

Back pain is a very common condition, affecting about 80% of people at some point in their lives. A physiotherapist demonstrates some simple back stretches to help prevent aches and pains.

Media last reviewed: 08/08/2013

Next review due: 08/08/2015

Compare your options

Take a look at a simple guide to the pros and cons of different treatments for ankylosing spondylitis

There is no cure for ankylosing spondylitis (AS), but treatment is available to help relieve the symptoms.

Treatment can also help delay or prevent the process of the spine fusing (joining up) and stiffening.

In most cases, treatment will involve a combination of exercise, physiotherapy and medication, which are described below.

There is a summary of the pros and cons of the available treatments, so you can compare your options.

Physiotherapy and exercise

Keeping active can improve your posture and range of spinal movement, along with preventing your spine from becoming stiff and painful.

As well as keeping active, physiotherapy is a key part of treating AS. A physiotherapist (a healthcare professional trained in using physical methods of treatment) can advise about the most effective exercises and draw up an exercise programme that suits you.

Types of physiotherapy recommended for AS include:

  • a group exercise programme – where you exercise with others
  • an individual exercise programme – you are given exercises to do by yourself
  • massage  your muscles and other soft tissues are manipulated to relieve pain and improve movement (the bones of the spine should never be manipulated as this can cause injury in people with AS)
  • hydrotherapy  exercise in water (usually a warm, shallow swimming pool or a special hydrotherapy bath); the buoyancy of the water helps make movement easier by supporting you, and the warmth can relax your muscles 

Some people prefer to swim or play sport to keep flexible. This is usually fine, although some daily stretching and exercise is also important.

If you're ever in doubt, speak to your physiotherapist or rheumatologist before taking up a new form of sport or exercise.

The National Ankylosing Spondylitis Society (NASS) provides detailed information about different types of exercise to help you manage your condition. 

Painkillers

You may need painkillers to manage your condition while you are being referred to a rheumatologist. The rheumatologist may continue prescribing painkillers, although not everyone needs them all the time.

Non-steroidal anti-inflammatory drugs (NSAIDs)

The first type of painkiller usually prescribed is a non-steroidal anti-inflammatory drug (NSAID). As well as helping to ease pain, NSAIDs can help relieve swelling (inflammation) in your joints.

Examples of NSAIDs include ibuprofen, naproxen and diclofenac.

When prescribing NSAIDs, your GP or rheumatologist will try to find the one that suits you, and the lowest possible dose that relieves your symptoms. Your dose will be monitored and reviewed as necessary.

Paracetamol

If NSAIDs are unsuitable for you, an alternative painkiller, such as paracetamol, may be recommended.

Paracetamol rarely causes side effects and can be used in women who are pregnant or breastfeeding. However, paracetamol may not be suitable for people with liver problems or those dependent on alcohol.

Codeine

If necessary, as well as paracetamol, you may also be prescribed a stronger type of painkiller called codeine.

Codeine can cause side effects including feeling sick, vomiting, constipation and drowsiness.

Anti-TNF medication

If your symptoms cannot be controlled using painkillers or exercising and stretching, anti-TNF (tumour necrosis factor) medication may be recommended. TNF is a chemical produced by cells when tissue is inflamed.

Anti-TNF medications are given by injection and work by preventing the effects of TNF, as well as reducing inflammation in your joints caused by ankylosing spondylitis.

Examples of anti-TNF medication include adalimumab, etanercept and golimumab.

These are relatively new treatments for AS, and their long-term effects are unknown.

However, they have been used for longer in people with rheumatoid arthritis, and this is providing clearer information about their long-term safety.

If your rheumatologist recommends using anti-TNF medication, the decision about whether they are right for you must be discussed carefully and your progress will be closely monitored. This is because anti-TNF medication can interfere with the immune system (the body’s natural defence system), increasing your risk of developing potentially serious infections.

NICE guidelines

The National Institute for Health and Care Excellence (NICE) has produced guidance about the use of anti-TNF medication for AS. NICE states that adalimumab, etanercept and golimumab may only be used if:

  • your diagnosis of ankylosing spondylitis has been confirmed
  • your level of pain is assessed twice (using a simple scale that you fill in) 12 weeks apart and confirms your condition has not improved
  • your Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is tested twice, 12 weeks apart, and confirms your condition has not improved  BASDAI is a set of measures devised by experts to evaluate your condition, by asking a number of questions about your symptoms
  • treatment with two or more NSAIDs for four weeks at the highest possible dose has not controlled your symptoms

After 12 weeks of treatment with anti-TNF medication, your pain score and BASDAI will be tested again to see whether they have improved enough to make continuing treatment worthwhile. If they have, treatment will continue and you will be tested every 12 weeks.

If there is not enough improvement after 12 weeks, you will be tested again at a later date or the treatment will be stopped.

Corticosteroids

Corticosteroids have a powerful anti-inflammatory effect and can be taken as tablets or injections by people with AS.

If a particular joint is inflamed, corticosteroids can be injected directly into the joint. After the injection, you will need to rest the joint for up to 48 hours.

It is usually considered wise to have a corticosteroid injection up to three times in one year, with at least three months between injections in the same joint. This is because corticosteroids injections can cause a number of side effects, such as:

  • infection in response to the injection
  • the skin around the injection may change colour (depigmentation)
  • the surrounding tissue may waste away
  • a tendon (cord of tissue that connects muscles to bones) near the joint may rupture (burst)

Corticosteroids may also calm down painful swollen joints when taken as tablets.

Disease-modifying anti-rheumatic drugs (DMARDs)

Disease-modifying anti-rheumatic drugs (DMARDs) are an alternative type of medication often used to treat other types of arthritis.

DMARDs may be prescribed for AS, although they are only beneficial in treating pain and inflammation in joints in areas of the body other than the spine.

Two DMARDs sometimes used to treat inflammation of joints other than the spine include sulfasalazine and methotrexate.

Surgery

Most people with AS will not need surgery.

However, in cases where a joint has become severely damaged, joint replacement surgery may be recommended to improve pain and movement in the affect joint. For example, if the hip joints are affected, a hip replacement may be carried out.

In rare cases, corrective surgery may be needed if the spine becomes badly bent.

Follow-up

As the symptoms of AS develop slowly and tend to come and go, you will need to see your rheumatologist or GP for regular check-ups.

They will make sure your treatment is working properly and may carry out physical assessments to assess how your condition is progressing. This may involve further sets of the same blood tests or X-rays you had at the time of your diagnosis.

Any complications of ankylosing spondylitis that arise will be treated as they develop.

Page last reviewed: 26/06/2014

Next review due: 26/06/2016

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