Overview
Ankylosing spondylitis, or AS, is a type of arthritis that primarily affects the spine and the sacroiliac (SI) joints, where the spine meets the pelvis. It can affect other joints and cause inflammation in the areas where tendons attach to bones. In severe cases, it can cause stiffness and loss of motion in the spine, changes in posture, and chronic pain.
AS is an autoimmune condition, meaning it is caused by the body’s own immune system reacting to healthy parts of the body. Unlike other autoimmune diseases, AS affects more men than women. It was previously thought that AS was as much as 9 times more common in men, but recent estimates suggest that ratio is closer to 3 to 1.
AS is 3 times more likely to affect men than women.
It is estimated that AS affects approximately 0.5% of adults in the U.S. But this may vary depending on location and the population studied.
Causes
In AS, inflammation in the spine and other joints leads to pain and stiffness in those joints. Like with other autoimmune diseases, the exact cause of that inflammation is unknown. Researchers believe that a complex combination of genetics and environmental factors causes the immune system to react abnormally. But it isn’t clear why the immune system’s response is directed at the spine and other affected joints.
Risk factors for AS include age, sex, and genetics. These aren’t causes but rather factors that make you more likely to develop AS.
AS is more common in young male adults, and there is a genetic component in the likelihood of developing it. According to one study, a person’s risk of AS is 8% if they have a first-degree relative with it.
A strong link has been found between AS and a gene called HLA-B27. The HLA-B gene family plays an important role in how the immune system functions. HLA-B27 is also found in people with other inflammatory conditions, but the connection with AS is stronger: Up to 85% of people with AS have HLA-B27. But not everyone with HLA-B27 gets AS.
In the U.S., HLA-B27 is much more common in non-Hispanic white people than in other ethnic groups (7.5% versus 3.5%). In groups with a higher prevalence of HLA-B27, AS is more common.
Having any of the following also increases the likelihood of AS:
Symptoms
The symptoms of AS depend on which areas of the body are affected, which varies from person to person. Also, as with many autoimmune diseases, fatigue (extreme tiredness) is a problem for most people with AS. Symptoms typically come on gradually, rather than suddenly.
Eighty percent of people with AS start to have symptoms before age 30.
Low back pain
Low back pain and stiffness are the most common symptoms of AS. Most people (up to 90%) experience back pain as their first symptom. Low back pain due to AS:
- Improves with exercise
- Is worse at night
- May travel down into the buttocks
Joint pain
Although the spine is most commonly affected, inflammation from AS can affect other places, either in joints or in the tendons and ligaments near joints. This means AS can cause pain and stiffness in the following areas:
- Hips
- Knees
- Ankles
- Shoulders
- Ribs/chest
Coexisting conditions
People with AS commonly have other autoimmune disorders, which can affect other parts of the body:
- Eyes: One in four people with AS have uveitis, which can cause eye redness, blurry vision, and sensitivity to bright light.
- Abdomen: Inflammatory bowel disease, such as Crohn’s disease and ulcerative colitis, occurs in about 7% of people with AS, especially women. This can cause abdominal pain and changes in bowel movements.
- Skin: Almost 10% of people with AS also have psoriasis.
Most people experience symptoms before age 30. AS is commonly diagnosed around age 35 and usually before age 45.
Treatment
Diagnosis
A specific test for AS does not exist. Because of this, and the fact that back and joint pain are relatively common among adults, it can take years for people with AS to get a diagnosis.
Getting a diagnosis often requires a combination of your:
- Symptoms
- Medical history
- Family medical history
- Physical examination
- Imaging tests
- Bloodwork
X-rays often show signs of inflammation at the SI joints, or sacroiliitis. But not all people with AS have typical X-ray findings. Some people have what is called a “non-radiographic” version of the disease. Research suggests some people with non-radiographic AS go on to develop signs of sacroiliitis on X-rays over time. So your provider may suggest getting an MRI of your spine and pelvis if they think you could have AS.
Blood tests that look for inflammation can be helpful when autoimmune diseases are a possibility. These include erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). They alone cannot diagnose or rule out AS, but they can provide extra information.
Testing for HLA-B27 may also be recommended. It’s not a diagnostic test but a piece of the puzzle that can help to get a diagnosis. Remember: A positive HLA-B27 test does not mean you have AS, and a negative test does not mean you don’t.
Some or all of these tests can be ordered by your primary care provider, but you may also need to see a rheumatologist to help with diagnosis. This is someone who specializes in diagnosing and treating autoimmune conditions.
Treatment
People who receive a diagnosis of AS will likely be treated by a rheumatologist. The goals of AS treatment are to:
- Reduce symptoms
- Maintain motion in the spine and joints
- Prevent permanent changes in posture
- Help people live well and keep their independence
Medications are typically recommended first to help with pain and inflammation (more on this below).
Exercise is also beneficial — for people with AS, it can reduce symptoms and inflammation. Research suggests that an exercise program guided by a trained physical therapist may be more beneficial than a home program.
If you are new to either exercise or AS, it’s a good idea to speak with your healthcare provider before starting a new exercise program. Be sure to avoid spinal manipulation in order to avoid injury.
In some cases, AS worsens despite treatment with medication. If AS is severe and negatively affects mobility or quality of life, surgery may be necessary. For example, hip replacement can improve motion and reduce pain related to hip arthritis. Spine surgery is usually reserved for people with severe posture changes. The decision to move forward with surgery should be made carefully and on an individual basis.
Medications
Medications that target inflammation or the immune system are often used to treat AS. Your rheumatologist can walk you through the possible side effects of each and help you decide which treatment is right for you.
Non-steroidal anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs (NSAIDs) are often very effective for treating AS, so they are recommended as first-line treatment. Examples include
- Indomethacin (Tivorbex, Indocin)
- Naproxen (Naprosyn, Anaprox DS)
- Celecoxib (Celebrex)
- Diclofenac (Arthrotec)
Research suggests that all NSAIDs are equally effective. Some people will need daily treatment, whereas others may take medication only when needed.
Biologic medications
Biologic disease-modifying medications target specific molecules or cells in the inflammatory process. If treatment with NSAIDs is insufficient, treatment with a tumor necrosis factor (TNF) inhibitor is recommended. Examples include:
- Adalimumab (Humira)
- Certolizumab pegol (Cimzia)
- Etanercept (Enbrel)
- Golimumab (Simponi)
- Infliximab (Remicade)
If a TNF inhibitor does not work well enough, other biologic options include secukinumab (Cosentyx) or ixekizumab (Taltz).
Medications & Collections
These drugs are vital for controlling and improving the health of individuals with this condition. They include both preventive and symptomatic treatments.
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