Ankylosing spondylitis (AS), which mainly affects young men, is often referred to as the “cancer that never dies” because it can lead to physical disability and seriously affect life and work in the absence of regular treatment. However, early diagnosis, early and long-term treatment and regular follow-up can lead to a “disease-free” state. Through more than 20 years of clinical practice in the treatment of numerous ankylosing spondylitis, the author has gradually developed some treatment experience, which is summarized below.
Experience 1 Exercise should be used throughout the treatment
For patients with ankylosing spondylitis, exercise is indeed no less important than drug therapy. As with rheumatoid arthritis and other diseases, the more exercise patients have, the better the control of the disease. This is because exercise relieves symptoms, prevents spinal and joint disability, builds muscle strength, increases lung capacity, and improves quality of life. It has been shown that after 6 months of exercise can also significantly improve self-confidence and joint flexibility and improve joint function. Gymnasts with ankylosing spondylitis rarely develop spinal ankylosis and disability, which is related to their long-term exercise and movement. A number of patients, once this disease is discovered, take time off work and are bedridden, which is a fundamental mistake.
Exercise intensity and programs vary depending on the condition It is important to emphasize that exercise for ankylosing spondylitis should be done carefully and without interruption, and that the exercise program and intensity vary with the duration of the disease and the site of involvement. If the disease is relatively long, there has been a hunchback, straight spine, chest expansion is limited, back exercises and chest expansion exercises should be emphasized, and because of the poor mobility of the spine, and easy to combine osteoporosis, to avoid the impact of strenuous exercise. Patients with shorter disease duration and better joint and spinal mobility can do some leisure exercises, such as radio gymnastics, swimming and Tai Chi. However, it is important to note that swimming should not be done in cool water, but in warm water, such as hot springs. There are special spas abroad for patients to use.
Continuity of exercise is crucial Continuity of exercise is more important than the intensity of exercise. Generally speaking, moderate intensity exercise (2-4 h/week) is more desirable than no exercise and high intensity exercise (>10h/week). At least 30 min per session at least 5 times per week.
Sitting, standing and lying postures are important in patients with ankylosing spondylitis
First, it is important to keep the body upright, avoid long-term bending and flexion, do not adopt a posture for a long time, and change the position appropriately to maintain the normal physiological curvature of the spine and prevent spinal deformity.
Secondly, try to sleep on a hard bed, use supine or prone position, avoid side lying, especially the flexion of the leg side lying position. Although the flexion position can reduce pain, it is easy to lead to hunchback deformity. If the cervical spine is involved, the pillow should be low or go to the pillow and lie flat to prevent the cervical spine from reverse arch deformity. If a pillow is used, it should be as low as possible to maintain the normal front arch without increasing the posterior protrusion of the upper thoracic vertebrae.
Again, when standing, head up, chest up, abdomen, if necessary, can stand with back against the wall to maintain good posture. Sitting should be straight-backed hard chair, keep the upper body straight, hip and knee flexion 90 degrees, avoid sitting on a low bench and sofa, avoid bending too long, causing spinal deformity.
Experience 2 Drug treatment should be different according to different types of diseases
Drug classification and characteristics
For the treatment of ankylosing spondylitis, the following classes of drugs are mainly available.
Nonsteroidal anti-inflammatory drugs are the first-line drugs, such as celecoxib, diclofenac sodium, meloxicam, and indomethacin, which relieve pain and morning stiffness, improve function and mobility, and may slow the progression of imaging in patients. Continued use is required for those with active and symptomatic disease, with attention to the risk of gastrointestinal, cardiovascular, and renal toxicities.
Palliative antirheumatic drugs include lorazepam, methotrexate, thalidomide and leflunomide. They can stop disease progression and achieve improved prognosis.
Biological agents The most used are anti-tumor necrosis factor alpha agents, which have good anti-inflammatory effects and can rapidly control the disease activity and stop the disease progression. According to the strength and nature of drug action, TNF inhibitors are divided into two categories: fusion protein class (domestic Ixepro and Qiangke, imported Enzyme) and monoclonal antibody class (including classical gram and Xumel), the former category is slightly weaker, but the side effects are slightly less.
Glucocorticoids If there is no extra-articular spinal comorbidity such as ophthalmia, systemic oral use is not advocated. Systemic oral hormones are mainly used for acute iritis and pulmonary involvement; intra-articular injection of hormones is suitable for refractory severe arthritis with only 1-2 ineffective NSAIDs to relieve local inflammation and reduce local pain as soon as possible; there is no indication for systemic use of hormones for mid-axis involvement in general.
Analgesics For those who fail the above drug therapy, have contraindication or poor tolerance, paracetamol or opioid analgesic treatment can be considered.
Selection and application strategies
Ankylosing spondylitis is classified as peripheral joint involvement, medial involvement, or both. In the case of peripheral joint involvement with large joint involvement in the lower extremities, the main drugs used are nonsteroidal anti-inflammatory drugs, lorazepam, leflunomide, methotrexate, elamod (edesine), and TNF inhibitors. The main drugs used in the type of spondylitis with mid-axis involvement are NSAIDs, anti-TNF agents, thalidomide and bisphosphonates. Among them, NSAIDs and TNF inhibitors are effective for both types.
When taking NSAIDs, if there are no adverse effects such as gastrointestinal, cardiovascular and renal damage, they can be taken continuously. In the case of more severe symptoms, with intractable tendon telangiectasia, combined hip involvement or iritis, TNF inhibitors are preferred. The earlier the TNF inhibitor is used, the more effective it is and the more likely it is to reduce the risk of recurrence, and long-term application may inhibit new bone formation in the spine. Screening for hepatitis B and tuberculosis is required prior to use, and regular application initially may be followed by gradual lengthening of the interval of use to maintain consolidation. During the first few days of each use, more rest is needed to avoid exertion-induced colds and infections, and the injection needs to be suspended in case of colds.
Experience 3 Salicyclovir is the most commonly used, and the details of its use should be noted
Salicyclovir is the most widely used second-line drug in the treatment of ankylosing spondylitis. It is mainly suitable for patients with ankylosing spondylitis with peripheral arthritis to improve peripheral joint symptoms; secondly, it can prevent and control iritis complicated by ankylosing spondylitis; it is also effective for co-infection of the intestinal tract (more than 60% of patients with ankylosing spondylitis have intestinal inflammation) and can inhibit microorganisms in the intestinal tract to improve the condition. Its dosing details are as follows.
Before use, it is necessary to know whether there is a history of allergy to sulfonamides, which should not be applied in allergic patients.
To prevent adverse drug reactions, it is recommended to increase gradually from a small dose, starting with 0.5 g per dose, 2 times/d, and then gradually increasing to 1 g per dose, 2 times/d, depending on the condition and drug response, and generally not recommended to increase to 3 g/d.
Drink more water and can be taken with sodium bicarbonate: acetosulfanilamide, a metabolite of salazosulfapyridine, has low solubility in acidic urine and easily precipitates crystals, causing mechanical irritation to the kidney, causing back pain and hematuria, and even urinary closure, etc., while its solubility increases in an alkaline environment. Therefore, when taking salazosulfapyridine for a long time or in large doses, drink more water and increase urine volume (urine volume should not be less than 1.5 L) to reduce the drug concentration in urine.
Do not take with acidic drugs: Some acidic drugs, such as vitamin C and pepsin combination, should not be combined with salazosulfapyridine to prevent acidification of the urine, which will reduce the solubility of the metabolite acetyl sulfonamide in the urine and precipitate crystals, resulting in crystalline urine damage to the kidney.
Allergy to salazosulfapyridine can be changed to mesalazine; if gastrointestinal reactions are relatively large, it can be changed to anal suppositories.
Salazosulfapyridine can be used in pregnant women during pregnancy, but the dose should not be >2 g/d, and should be accompanied by folic acid supplementation (to reduce the risk of cleft lip), in those who deliver a full-term newborn (without glucose-6-phosphate dehydrogenase deficiency), and in mothers during lactation. For males, 3 months off the drug before conception (salazosulfapyridine can cause spermopenia in men, but it is generally reversible and can be recovered after a few months off the drug).
Experience 4 The combination of salazosulfapyridine and thalidomide is more effective
The combination of lorazepam and thalidomide is recommended for the treatment of ankylosing spondylitis not only for its efficacy, but also for its low adverse effects and inexpensive price. To avoid possible adverse effects of thalidomide (e.g., drowsiness), it should be taken before going to sleep and gradually increased from small doses, such as starting with 25-50 mg per night, and the tolerated dose in the country is often within 100 mg per day. To prevent possible limb numbness, vitamin B6 can be used in combination, and should be discontinued once limb numbness occurs. For those who develop constipation due to thalidomide, the combination of total peony glycosides may be used. The use of thalidomide is absolutely prohibited in women during pregnancy.
Experience 5 The prognosis of hip joint involvement is poor and should be treated actively
Once hip involvement occurs, the prognosis is often poor and requires active treatment, often requiring a combination of multiple drugs, similar to the treatment regimen for rheumatoid arthritis, such as salazosulfapyridine + methotrexate, salazosulfapyridine + thalidomide, methotrexate + TNF inhibitors, etc. Especially, TNF inhibitors combined with methotrexate can significantly improve hip joint disease activity and inhibit imaging progression. The therapeutic dose of methotrexate should not exceed 0.3 mg/kg, and 10 mg of folic acid tablets should be added after 2 days of methotrexate to reduce the adverse effects of methotrexate.
Experience 6 Patients with advanced disease should have their bone density checked, and if there is reduced bone mass or osteoporosis, bisphosphonates should be chosen
Because patients with advanced ankylosing spondylitis have limited spinal activity and go out less, resulting in receiving less sunlight, they often have a combination of bone loss or osteoporosis and should have bone density and bone metabolism markers. Once osteoporosis or bone loss occurs, calcium, vitamin D, and bisphosphonates should be used. In addition to inhibiting osteoclasts to treat osteoporosis, bisphosphonates can also relieve the pain of ankylosing spondylitis, killing two birds with one stone.
Lesson 7: Actively treat patients with concurrent iritis to prevent further eye damage
Some patients with ankylosing spondylitis complicated by iritis need to minimize eye use, use computers less often, and drive long distances less often. To prevent pupillary adhesions, topical hormonal eye drops and pupil dilators can be used, and hormones can be injected subconjunctivally or parabulbarly if necessary. Prednisone 1 mg/(kg?d) should be given orally, reduced after 7 days, and discontinued after 3-4 weeks, and may be combined with salazosulfapyridine (which reduces the frequency of ophthalmic episodes and post-iris adhesions) and/or TNFα inhibitors (monoclonal antibodies are more effective than fusion proteins). For hormone ineffective or hormone-dependent or posterior uveal involvement, methotrexate or leflunomide may be used alone or in combination. For posterior uveal involvement where the above is not effective, intravenous immunoglobulin may be administered.
Experience 8 Surgery may be considered for patients with advanced disease that severely affects quality of life
In general, certain patients with advanced ankylosing spondylitis who develop a hunchback deformity with a spine of more than 60 degrees or who are unable to walk because of severe damage to the hip joint may seek orthopedic surgery, including spinal orthopedics and hip replacement.
Total hip arthroplasty is feasible if imaging shows structural damage to the hip joint with intractable pain or loss of function; spinal osteotomy is feasible if the spine is severely deformed and limited in movement; acute vertebral fractures require surgical treatment according to the situation.