Ankylosing spondylitis (AS) is a chronic inflammatory disease that mainly affects the sacroiliac joints, spinal prominences, paraspinal soft tissues and peripheral joints, and may be accompanied by extra-articular manifestations. The main clinical manifestations are back, back, neck, hip and hip pain, as well as joint swelling and pain, and in severe cases, spinal deformity and joint ankylosis may occur.
The disease has been described in ancient Egypt since 1691, but it has been regarded as a variant of rheumatoid arthritis and called “rheumatoid arthritis, central” or “rheumatoid spondylitis”. “. It was not until 1973 that AS was discovered to be associated with HLA-B27, and then as the understanding of AS grew, it was separated from rheumatoid arthritis and called the category of spondyloarthritis. The incidence of AS in women is now generally considered to be lower than in men, with a male to female ratio of (2-3):1. Peripheral joint involvement, cervical spine and upper back pain are more common in women, with mild clinical symptoms and a good prognosis. Spondyloarthritis is a group of diseases with common clinical features, previously known as spondyloarthropathies or seronegative spondyloarthropathies, including AS, reactive arthritis, psoriatic arthritis, inflammatory bowel disease arthritis, juvenile spondyloarthropathies, and undifferentiated spondyloarthropathies, which have a high rate of HLA-B27 gene positivity, familial aggregation These diseases have a high prevalence of HLA-B27 gene positivity, familial aggregation, involvement of the mid-axis and predominantly lower extremity joints, tendonitis and some characteristic extra-articular manifestations. All of these diseases may progress to AS.
Causes: Genetic and environmental factors play a role in the development of the disease. The development of AS has been shown to be closely related to HLA-B27, with a significant tendency for familial aggregation. The rate of HLA-B27 positivity in the normal population varies greatly by race and region, ranging from 6% to 8% in China, but the rate of HLA-B27 positivity in Chinese AS patients is about 90%. Other data show that the prevalence of AS is 4% in the patient’s family line and up to 11%-25% in the first-degree relatives of HLA-B27-positive AS patients, suggesting an increased risk of disease in HLA-B27-positive individuals or those with a family history of AS. However, approximately 80% of HLA-B27-positive individuals do not develop AS, and approximately 10% of AS patients are HLA-B27-negative, suggesting that other factors are involved in the pathogenesis, such as intestinal bacteria and intestinal inflammation.
Clinical presentation: Prevalent group: 10 to 40 years old, with an average age of onset of 25 years. It is more common in males than females, with a male to female incidence ratio of (2-3):1. The incidence is higher in those with a positive family history of AS. Disease symptoms: The onset of the disease is insidious. Patients gradually develop pain and/or stiffness in the hip and lower back, especially when lying down for a long time (at night) or sitting for a long time, with difficulty in turning over, and stiffness in the lower back is obvious in the morning or when sitting for a long time, but relieved after activity. Some patients feel severe pain in the hip and hip area, which occasionally radiates to the periphery. In the early stage of the disease, the pain is mostly intermittent on one side, and after a few months, the pain is mostly persistent on both sides. As the disease progresses from the sacroiliac joint to the lumbar spine, thoracic and cervical spine, pain, restricted movement or spinal deformity will occur in the corresponding areas. It has been reported that about 45% of patients in China start with peripheral arthritis. 24% to 75% of AS patients develop peripheral joint lesions at the beginning or during the course of the disease, mostly in the knee, hip, ankle and shoulder joints, with occasional involvement of the elbow and small joints of the hand and foot. Asymmetric, few-joint or single-joint arthritis and arthritis of the large joints of the lower extremities are the characteristics of peripheral arthritis in this disease. In our patients, arthritis or arthralgia of the knee and other joints, except the hip, is mostly transient and rarely or hardly causes joint destruction and disability. The hip joint is involved in 38% to 66% of cases, showing localized pain, limitation of movement, flexion twist and joint ankylosis, most of which are bilateral, and 94% of the hip symptoms start within the first 5 years after the onset of the disease. The disease is more likely to occur at a younger age and in those with peripheral joint disease.
The systemic manifestations of the disease are usually minor, but a few severe cases have fever, fatigue, wasting, anemia, or other organ involvement. Metatarsal fasciitis, Achilles tendinitis, and other areas of tendon terminal disease are common in this disease. 1/4 of patients develop uveitis during the course of the disease, alternating unilaterally or bilaterally, which usually resolves spontaneously and can lead to visual impairment with repeated attacks. Neurological symptoms arise from compressive spinal neuritis or sciatica, vertebral fractures or incomplete dislocations, and cauda equina syndrome, the latter of which can cause impotence, nocturnal incontinence, bladder and rectal dullness, and loss of ankle reflexes. Very few patients develop fibrosis of the upper lobe of the lung. It is sometimes accompanied by cavity formation and considered tuberculosis, and can also be exacerbated by concurrent mycobacterial infections. Focal mesangial necrosis of the aortic root can cause annular dilatation of the aorta and shortening and thickening of the aortic valve cusps, resulting in incomplete aortic valve closure and conduction disturbances seen in 3.5% to 10% of patients. Ankylosing spondylitis can be complicated by IgA nephropathy and amyloidosis.
The disease often affects young adults, and patients are often at an important stage of learning and working, which can have a major impact on patients if they are not treated appropriately, resulting in decreased ability to learn and work, or even disability. The severity of the disease varies greatly in clinical manifestations. In some patients, the disease continues to progress repeatedly, and within one to two years, significant spinal ankylosis and hunchback deformation may appear, and some patients with serious hip involvement may be bedridden for a long time; while some patients may remain relatively stationary for a long time and can work and live normally. However, the prognosis is poor in patients with young age of onset, early hip involvement, recurrent iridocyclitis and secondary amyloidosis, delayed diagnosis, untimely and unreasonable treatment, and failure to adhere to long-term functional exercise.
Laboratory and ancillary tests.
Laboratory tests: elevated platelets, anemia, increased sedimentation and elevated C-reactive protein may be caused by AS activity, although there are still some AS patients with clinically significant symptoms such as low back pain but normal indexes mentioned above. The rate of HLA-B27 positivity in our AS patients is about 90%, while the rate of HLA-B27 positivity in our normal population is 6%-8%, about 80% of HLA-B27 positive people do not have AS, and about 10% of AS patients are HLA-B27 negative.
X-ray: blurring of the subchondral bone margin of the sacroiliac joint, bone erosion, blurring of the joint space, increased bone density and joint fusion. The degree of lesion of sacroiliac arthritis on X-ray is usually classified into 5 grades: grade 0 is normal; grade I is suspicious; grade II has mild sacroiliac arthritis; grade III has moderate sacroiliac arthritis; grade IV has joint fusion ankylosis. X-ray manifestations of the spine include vertebral osteoporosis and square changes, blurring of the vertebral tubercle, calcification of the paravertebral ligaments, and bone bridge formation. Extensive and severe ossifying bridges in the late stage are called “bamboo-like spine”. Bone erosion of the pubic symphysis, sciatic tuberosity, and tendon attachment points (e.g., heel bone), with reactive sclerosis and villous changes in adjacent bone, may result in new bone formation.
CT of sacroiliac joint: increased density of sacroiliac joint, blurring of joint space, mild bone erosion, obvious destruction and joint fusion.
MRI of sacroiliac joint: subchondral fat accumulation; bone marrow edema; irregular thickening and distortion of cartilage, irregular and fragmented cartilage surface; bone erosion.
Ultrasound imaging: suitable for the diagnosis of tendon involvement, tendon telangiectasia, synovitis, bursitis, cysts and erosion and erosion of cartilage and subchondral bone of the joint surface. Therapeutic examinations such as percutaneous puncture and drainage under ultrasound guidance and drug injection are especially suitable for hip joints that are deep, or joints with complex structures and rich local blood flow.
Diagnostic criteria: Different criteria have been used in recent years, but the New York criteria of 1966, or the revised New York criteria of 1984, are still used. However, for those who temporarily do not meet the above criteria, they can refer to the European preliminary diagnostic criteria for spondyloarthropathies, and those who meet them can also be included in this category for diagnosis and treatment, and follow-up observation.
1. New York criteria (1966): Bilateral or unilateral sacroiliac arthritis confirmed by X-ray (graded according to the aforementioned grade 0-IV) with one or two of the following clinical manifestations, respectively, namely: (i) limitation of lumbar spine motion in all three directions of anterior flexion, lateral flexion and posterior extension; (ii) history or existing symptoms of low back pain; and (iii) thoracic extension less than 2.5 cm. based on the above, the diagnosis of definite ankylosing spondylitis Requirements: X-ray confirmed grade III-IV bilateral sacroiliac arthritis with at least 1 of the above clinical manifestations; or X-ray confirmed grade III-IV unilateral sacroiliac arthritis or grade II bilateral sacroiliac arthritis with 1 or 2 of the above clinical manifestations, respectively.
2. Revised New York criteria (1984): ① the duration of lower back pain lasting at least 3 months, with pain improving with activity but not relieved by rest; ② restricted movement of the lumbar spine in the anterior-posterior and lateral flexion directions; ③ thoracic extension less than the normal value for the same age and sex; ④ bilateral sacroiliitis grade II-IV, or unilateral sacroiliitis grade III-IV. The diagnosis of ankylosing spondylitis can be confirmed if the patient has ④ and any 1 of ①~③ respectively.
3. European Spondyloarthropathy Study Group criteria: inflammatory spondylodynia or asymmetric synovitis predominantly in the joints of the lower extremities with any of the following additional items, namely: ① positive family history; ② psoriasis; ③ inflammatory bowel disease; ④ urethritis, cervicitis or acute diarrhea within 1 month prior to arthritis; ⑤ alternating bilateral hip pain; ⑥ tendon terminal disease; ⑦ sacroiliac arthritis.
Differential diagnosis.
1. non-specific low back pain: most low back pain is in this category of patients, which includes: lumbar muscle strain, lumbar muscle spasm, spinal osteoarthritis, cold-irritated low back pain, etc. This type of low back pain category does not have the characteristics of inflammatory low back pain of AS, and is easily identified by performing sacroiliac joint X-ray or CT examination and performing relevant laboratory tests such as erythrocyte sedimentation rate and C-reactive protein.
2. Gluteal myofasciitis: this disease often presents with unilateral upper gluteal pain, which needs to be differentiated from AS. However, the pain is not severe and does not usually cause difficulty in movement, and there is no aggravation of prolonged recumbency.
3. Lumbar disc prolapse: disc prolapse is a common cause of inflammatory low back pain. The disease is limited to the spine without systemic manifestations such as fatigue, wasting, fever, etc. All laboratory tests including blood sedimentation are normal. The main difference between it and AS can be confirmed by CT, MRI or vertebral canal angiography.
4. iliac dense osteoarthritis: This disease is mostly seen in young women, and its main manifestation is chronic lumbosacral pain and stiffness. Clinical examination is not abnormal except for muscle tension in the lumbar region. The diagnosis mainly relies on the X-ray anteroposterior radiograph, which typically shows a distinct osteosclerotic area in the iliac bone along the middle and lower 2/3 of the sacroiliac joint, triangular in shape with the tip upward, uniform in density, without invasion of the sacroiliac joint surface and without joint stenosis or erosion, so it is different from AS. The disease is not characterized by obvious sitting or lying pain for a long time, and the treatment with NSAIDs is not as effective as AS. The difference between the two diseases is also evident. MRI of the sacroiliac joint may be helpful, but a comprehensive clinical judgment is still needed.
Rheumatoid arthritis: In the early stage of AS, it is especially important to differentiate from rheumatoid arthritis when peripheral arthritis is the main manifestation. (1) AS is more common in men and rheumatoid arthritis is more common in women. (2) AS invariably has sacroiliac joint involvement, whereas rheumatoid arthritis rarely has sacroiliac joint lesions. (3) AS involves the whole spine from the bottom up, while rheumatoid arthritis only affects the cervical spine. In AS, peripheral arthritis is a small number of joints, asymmetric and predominantly in the joints of the lower extremities, and is often associated with tendonitis; in rheumatoid arthritis, it is multi-joint, symmetric and can develop in both large and small joints of the extremities. ⑤ AS does not have rheumatoid nodules as seen in rheumatoid arthritis. (6) AS is negative for rheumatoid factor, while rheumatoid arthritis has a positive rate of 60% to 95%. (7) AS is predominantly HLA-B27 positive, while rheumatoid arthritis is associated with HLA-DR4.
6. gout: some patients with this disease have long-lasting arthritic episodes in the lower extremities, and sometimes the blood uric acid does not appear to be elevated during the onset of the disease, so it is often necessary to differentiate from peripheral arthritis caused by AS. In this case, the clinical features of both diseases should be carefully differentiated.
7. diffuse idiopathic bone hypertrophy (DISH): also known as ankylosing bone hypertrophy, or Forestier’s disease. It is a non-inflammatory disease with spinal pain, stiffness, and progressively more limited spinal motion. The clinical presentation and x-ray findings are often similar to those of AS. However, calcification of the ligaments, often involving the cervical and low thoracic vertebrae, is often seen on x-ray, with flowing calcifications and ossifications connecting at least 4 anterolateral vertebral bodies, without erosion of the sacroiliac and spondylolisthesis joints, without increased stiffness in the morning, with normal blood sedimentation and negative HLA-B27. The disease can be differentiated from AS based on the above characteristics.
8. Metabolic bone disease: Metabolic bone disease such as hyperparathyroidism and abnormal calcium and phosphorus metabolism often presents with painful deformation of the spine, shortening of height, hip pain, etc. Significant osteoporosis or sclerosis of the bone can be seen on imaging, but there is no blurring or destruction of the sacroiliac joint surface.
9. Late onset spondyloepiphyseal dysplasia with progressive arthropathy: This disease is a genetic abnormality resulting in epiphyseal dysplasia. Patients usually develop short trunk dwarfism after 5 to 10 years of age due to growth arrest, and mild to moderate pain and limitation of movement in the lumbar hip and peripheral joints. X-rays show lateral/retroflexion deformity of the spine, flattened vertebral bodies, widened anterior-posterior and transverse diameters, lack of ossification of the upper and lower edges of the vertebral bodies in the shape of a “transverse vase”, small pelvis, absence of the auricular surface of the iliac wing, shallow acetabulum, widened space between the sacroiliac joint and the pubic symphysis. The gap is widened, the femoral neck is thick and short, and the femoral head is flattened and the surface is uneven in older individuals; the peripheral joint gap is narrowed, the epiphysis and bone ends are enlarged, and osteoarthritis develops secondary to the disease. The physical appearance of the disease is similar to that of advanced AS, and sometimes some abnormal changes may occur in the sacroiliac joint due to osteoporosis and widening of the gap, so it needs to be differentiated from AS.
Treatment options and principles There is no radical cure for AS. However, if patients are diagnosed in time and treated appropriately, they can achieve symptom control and improve the prognosis. Non-pharmacological, pharmacological and surgical treatments should be used to relieve pain and stiffness, control or reduce inflammation, maintain good posture, prevent deformation of the spine or joints, and correct deformed joints if necessary, in order to improve and enhance the quality of life of patients.
I. Non-pharmacological treatment ① Education of patients and their families about the disease is an indispensable part of the overall treatment plan, which helps patients to actively participate in treatment and cooperate with physicians. The long-term plan should also include the patient’s psychosocial and rehabilitation needs. ② Advising patients to engage in careful and uninterrupted physical exercise to obtain and maintain the best position of the spinal joints, strengthen paravertebral muscles and increase lung capacity is no less important than pharmacological treatment. (③Standing should be done in a posture that keeps the chest upright, abdomen tucked in and eyes level in front as much as possible. The sitting position should also keep the chest upright. One should sleep on a hard bed and take more supine positions to avoid positions that promote flexion deformity. Pillows should be short and should be discontinued once upper thoracic or cervical spine involvement occurs. ④ Reduce or avoid physical activities that cause persistent pain. Measure height regularly. Keeping height records is a good measure to prevent early spinal curvature that is not easily detected. ⑤ Inflammatory joints or other soft tissue pain choose the necessary physical therapy.
II. Drug treatment
(a) General drugs
1. non-steroidal anti-inflammatory drugs: this class of drugs can quickly improve the patient’s low back and hip back pain and stiffness, reduce joint swelling and pain and increase the range of motion, whether early or late AS patients are preferred for symptomatic treatment. There is a wide variety of NSAIDs, but their efficacy on AS is roughly equivalent. The following drugs are available: indomethacin suppositories 50 mg or 100 mg, inserted into the anus once or twice daily; acimexin 90 mg once daily; diclofenac sodium usually at a total daily dose of 75-150 mg; celecoxib 200 mg twice daily; loxoprofen sodium 60 mg three times daily; and meloxicam 15 mg once daily. Because most of the pain in AS is pronounced at night, the above drugs are most effective when applied at bedtime. The most common adverse effects of these drugs are gastrointestinal discomfort and a few can cause ulcers, while suppositories are absorbed through the rectum, which can reduce gastrointestinal side effects, and celecoxib has less gastrointestinal side effects; other less common ones are headache, dizziness, liver and kidney damage, hematocrit, edema, hypertension and allergic reactions. The physician should choose one anti-inflammatory drug for each patient. The use of 2 or more anti-inflammatory drugs at the same time will not increase the efficacy, but will increase the adverse drug reactions and even have serious consequences. Anti-inflammatory drugs usually need to be used for about 2 months, after the symptoms are completely controlled, the dose should be reduced and consolidated for a period of time with the minimum effective amount, and then consider stopping the drug, too soon to stop the drug is likely to cause recurrence of symptoms, such as a drug treatment for 2 to 4 weeks is not effective, should be changed to other anti-inflammatory drugs of different categories, in the process of drug use should always pay attention to monitor the adverse drug reactions and timely adjustment. This class of drugs has anti-inflammatory effects rather than simple pain relief, especially in recent years, it was found that long-term continuous application of this class of drugs may slow down the progression of the disease, which illustrates the importance of this class of drugs in the treatment of AS, therefore, it is currently advocated that AS patients should apply these drugs without hesitation as long as they have low back pain, and should not prevent the emergence of side effects and Otherwise, long-term pain and stiffness will easily lead to spinal stiffness and hunchback deformity.
2. Liunisulfapyridine: This drug can improve joint pain, swelling and stiffness in AS, and reduce serum IgA levels and other laboratory activity indicators. It is especially suitable for improving peripheral arthritis in AS patients, and has the effect of preventing recurrence and reducing lesions in the anterior uveitis complicated by this disease. To date, there is a lack of evidence for the therapeutic effect of this drug on the mesial arthropathy of AS and for improving the prognosis of the disease. The usual recommended dosage is 2.0 g per day, divided into 2-3 oral doses. It has a slow onset of action, usually 4 to 6 weeks after dosing. To increase patient tolerability, the dose is usually started at 0.25 g 3 times daily and then increased by 0.25 g weekly until 1.0 g twice daily, or the dose and duration of treatment are adjusted according to the condition or patient response to treatment and maintained for 1 to 3 years. To compensate for the slow onset of action of salazosulfapyridine and its weak anti-inflammatory effect, a fast-acting NSAID is usually used in combination with it. Adverse reactions include gastrointestinal symptoms, rash, hematocrit, headache, dizziness, and reduced spermatozoa and abnormal morphology in men (reversible with discontinuation of the drug). It is contraindicated in patients with sulfonamide hypersensitivity.
3. Methotrexate: Methotrexate can be used in patients with active AS when treatment with salbutamol and NSAIDs is ineffective. However, it has been observed by comparison that this product only improves the manifestations of peripheral arthritis, low back pain, stiffness and iritis, as well as ESR and CRP levels, while there is no evidence of improvement in radiographic lesions of the medial joints. Usually methotrexate 7.5 to 15 mg, with individual severe cases increasing the dose as appropriate, is administered orally or by injection once a week for a period ranging from 0.5 to 3 years. At the same time, one non-steroidal anti-inflammatory drug can be used. Although low-dose methotrexate has the advantage of fewer adverse effects, its adverse effects are still a problem that must be noted in treatment. These include gastrointestinal discomfort, liver injury, interstitial lung inflammation and fibrosis, hematocrit, alopecia, headache and dizziness, etc. Therefore, routine blood tests, liver function and other related items should be reviewed regularly before and after the drug is administered.
4. Leflunomide: This drug is more effective in the peripheral arthritis of AS, and some reports can also reduce the progression of inflammation of the sacroiliac joints, this drug is mainly used in the clinical treatment of extraspinal manifestations of AS. The most common side effect of this drug is hepatic impairment, so it is recommended to use hepatoprotective drugs during the application of this drug, and liver function should be checked every 2-4 weeks at the beginning of the drug, and then every 3-6 months. Loss of appetite, pruritic rash (often appearing after a long period of drug use), weight loss, etc. may also appear during the course of the drug treatment.
5. glucocorticoids: often referred to as “hormones” in clinical practice. In a few cases where symptoms cannot be controlled even with high doses of anti-inflammatory drugs, methylprednisolone 15 mg is given as a shock treatment for 3 days, which can temporarily relieve pain. For lower back pain that cannot be controlled by other treatments, glucocorticoid sacroiliac joint injection under the guidance of CT can improve the symptoms in some patients, and the efficacy can last for about 3 months. Long-acting corticosteroid joint cavity injections are feasible for long-term monoarticular effusion associated with this disease. Repeated injections should be given at intervals of 3~4 weeks, usually no more than 2~3 times. Oral glucocorticoid therapy not only cannot stop the development of the disease, but also brings adverse effects due to long-term treatment.
6. Thalidomide (thalidomide, reaction stop): Some patients with refractory AS showed significant improvement in clinical symptoms, ESR and CRP after application. The initial dose of 50 mg/d was increased by 50 mg every 7 to 10 days to 150-200 mg/d for maintenance. After the discovery of the anti-rheumatic effect of this drug, Professor Huang Feng of the Department of Rheumatology, PLA General Hospital and others took the lead in conducting more in-depth clinical and experimental studies on it, and confirmed through a large number of clinical practice that the drug is effective in AS, especially in some patients. However, the adverse reactions of this product are relatively more common, including drowsiness, dizziness, thirst, constipation, increased dandruff, and the rare adverse reactions include decreased white blood cells, elevated liver enzymes, microscopic hematuria and tingling sensation at the fingertips, etc. Those who choose this treatment should be closely observed, and blood and urine routine, liver and kidney functions should be checked every 2-4 weeks during the initial period of use. For long-term users, regular neurological examination should be done to detect possible peripheral neuritis in time. The drug may cause short limb malformation (seal fetus) in the fetus of pregnant women, therefore, the drug should be prohibited for pregnant women and patients (including men) who intend to have children in the near future.
7. Traditional Chinese medicine: Traditional Chinese acupuncture and moxibustion therapy and traditional Chinese medicine have certain therapeutic effects on AS.
(ii) Biological agents are monoclonal antibodies or recombinant products of natural inhibitory molecules that selectively target molecules or receptors involved in the immune response or inflammatory process. Biologics target the pathogenesis of rheumatic diseases more specifically than conventional immunosuppressive therapy and theoretically have the potential to control the progression of the disease fundamentally without affecting the normal immunity against infection. The advent of this class of drugs has led to a new phase in the treatment of rheumatic diseases such as AS. A growing body of evidence as well as clinical practice confirms the efficacy of anti-tumor necrosis factor (TNF)-alpha biologics in AS and spondyloarthritis, and they have been found to be more effective in AS and spondyloarthritis than in rheumatoid arthritis. At present, three types of anti-TNF-α biologics have been marketed in China.
1. Etanercept: It is a fusion protein expressed in mammalian cell lines by linking DNA encoding the soluble portion of the human TNF p75 receptor to DNA encoding the human IgG1Fc segment molecule, which reversibly binds to TNF-α and competitively inhibits the binding of TNF-α to the TNF receptor site. The recommended use is 25 mg subcutaneously twice a week, or 50 mg subcutaneously once a week, both of which have similar efficacy in AS. The author found that intra-articular injection of 25mg was effective in relieving the symptoms of peripheral arthritis in AS and rheumatoid arthritis, with rapid onset of action, longer duration of efficacy, and no significant local adverse effects. Ltd. and “Enbrel” produced by Pfizer Inc.
2. Infliximab: It is a human/mouse chimeric anti-TNF-α specific IgG1 monoclonal antibody. The recommended use for the treatment of AS is: 5 mg/kg intravenously, with the same dose repeated at weeks 2 and 6 after the first injection, and every 6 weeks thereafter. (Remicade)” produced by Xi’an Janssen Pharmaceutical Co., Ltd. is this kind of preparation.
3. Adalimumab: It is a fully humanized anti-TNF-α specific IgG1 monoclonal antibody. The recommended use is 40 mg subcutaneously once every 2 weeks. Humira, manufactured by Abbott Laboratories, is currently available.
All three of these anti-TNF-α biologics have a rapid onset of action (a few hours to 24 hours) and good efficacy. The majority of patients can rapidly achieve significant improvements in morning stiffness, low back pain, peripheral arthritis, tendon terminal inflammation, chest expansion, ESR and CRP, etc. After a period of application, patients’ physical function and health-related quality of life can be significantly improved, especially some newly emerged spinal dysfunction can be restored. Anti-TNF-α biologics have been widely recognized for their excellent efficacy since they were first applied in the treatment of AS in the late 20th century. In particular, this class of drugs is a better choice for the treatment of patients with active AS, who are primarily affected in the mid-axis and are often poorly treated with conventional drugs. The recommended usage of the aforementioned drugs is the full dose usage during the active phase of AS. After the disease is controlled with the full dose of these agents for 2 to 3 months, the interval of dosing can be gradually lengthened and other types of drugs can be used at the same time, and many patients will not have significant relapse of the disease. I clinically found that some patients with 25 mg of etanercept injected every 2 to 4 weeks for several years while using some NSAIDs can have their disease effectively controlled. Admittedly, the price of this class of drugs is high, and currently in the vast majority of domestic areas has not entered the scope of health insurance reimbursement, limiting its widespread use in China, however, for domestic preparations used in sufficient quantities for 2 months after lengthening the drug interval use, a considerable number of patients can still afford its cost.
A major disadvantage common to anti-TNF-α biologics is that they can reduce the body’s resistance to tuberculosis bacteria, so patients must be screened for tuberculosis infection before preparing for use, including: asking whether there is a history of tuberculosis, lung imaging and tuberculin pure protein derivative test (PPD test), and TB-ELISPOT test if available. Patients with a history of tuberculosis and old foci of tuberculosis found in the lungs should be prohibited from using anti-TNF-α biologics; patients with a strong positive reaction to the PPD test alone should be temporarily avoided and can be treated with anti-tuberculosis drugs for a period of time so that the reaction to the PPD test is reduced and then combined with anti-tuberculosis drugs; patients with a (++) reaction to the PPD test alone should use this class of drugs with caution and, if necessary Combine with anti-tuberculosis drugs if necessary. Close contact with patients with active tuberculosis should be avoided during treatment with this class of drugs.
This class of agents may also cause several other types of adverse reactions, including skin reactions at the injection site, increased risk of bacterial infection, aggravation of active viral hepatitis B, aggravation of pre-existing congestive heart failure, and neurodemyelinating lesions in individual patients. In addition, a small number of patients may experience infusion reactions to infliximab, and close observation is recommended when the drug is used for the first time. However, in general, biological agents are still relatively safe, and their safety is similar to that of traditional disease-modifying anti-rheumatic drugs, with good prospects for clinical application.
Third, surgical treatment: joint space narrowing, ankylosis and deformity caused by hip joint involvement are the main causes of disability in this disease. For patients with significant narrowing of the hip joint space or femoral head necrosis deformation, artificial total hip replacement can be considered in order to improve the joint function and quality of life. After the replacement, most patients’ joint pain is controlled, some patients’ function is normalized or nearly normalized, and 90% of the life expectancy of the replaced joint is more than 10 years. For patients with more serious deformity of the spine in forward flexion or scoliosis, which leads to obvious obstacles to life, such as the inability to see the road a few meters away when walking, such patients can consider spinal vertebral osteotomy to correct the deformity, but this type of surgery is risky and may cause damage to the spinal cord and lead to lower limb paraplegia, so for those who do not have very serious spinal deformity, surgery is not recommended. The development of the deformity can be slowed down or inhibited to some extent by physical therapy and rehabilitation exercises under active medical treatment.
Prognosis of the disease: It should be emphasized that the degree of severity of the clinical manifestation varies greatly, with some patients having repeated and continuous progression of the disease and others being in a relatively quiescent state for a long time and being able to work and live normally. However, the prognosis is poorer in patients with younger age of onset, earlier involvement of the hip, recurrent episodes of iridocyclitis and secondary amyloidosis, delayed diagnosis, untimely and unreasonable treatment, and non-adherence to long-term functional exercise. Although the prognosis of this disease has been greatly improved by the advent of biologic agents, it is still a chronic progressive disease that is difficult to cure completely and should be followed for a long time under the guidance of a specialist.