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The general principles of managing chronic arthritis (see above) apply equally well to ankylosing spondylitis The importance of postural and breathing exercises should be stressed
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The ESR is elevated in 85% of cases, but serologic tests for rheumatoid factor are characteristically negative Anemia may be present but is often mild HLA-B27 is found in 90% of white patients and 50% of black patients with ankylosing spondylitis Because this antigen occurs in 8% of the healthy white population (and 2% of healthy blacks), it is not a specific diagnostic test
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The NSAIDs are used in the treatment of this disorder Of these, indomethacin appears to be the most effective, though it can be quite toxic The dosage of indomethacin is usually 25 50 mg orally three times a day, but the smallest effective dose should be used Indomethacin may produce a variety of untoward reactions, including headache, giddiness, nausea and vomiting, peptic ulcer, renal insufficiency, depression, and psychosis Other NSAIDs are valuable alternatives and may be used as primary therapy Sulfasalazine (1000 mg twice daily) is sometimes useful for the peripheral arthritis in patients with spondyloarthropathies but has little symptomatic effect on spinal and sacroiliac joint disease Curiously, corticosteroids have minimal impact on the arthritis particularly the spondylitis of ankylosing spondylitis Studies with TNF inhibitors demonstrate that these agents are highly effective in both the spinal and peripheral arthritis of ankylosing spondylitis Either etanercept (25 mg subcutaneously twice a week) or infliximab (5 mg/kg every other month by IV infusion) is reasonable for patients whose symptoms are refractory to physical therapy and other interventions
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The earliest radiographic changes are usually in the sacroiliac joints In the first few months of the disease process, the sacroiliac changes may be detectable only by MRI Later, erosion and sclerosis of these joints are evident on plain radiographs Involvement of the apophysial joints of the spine, ossification of the annulus fibrosus, calcification of the anterior and lateral spinal ligaments, and squaring and generalized demineralization of the vertebral bodies may occur in more advanced stages The term bamboo spine has been used to describe the late radiographic appearance of the spinal column Additional radiographic findings include periosteal new bone formation on the iliac crest, ischial tuberosities and calcanei, and alterations of the pubic symphysis and
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and often the joint involvement is asymmetric Pitting of the nails and onycholysis are frequently associated 4 A severe deforming arthritis (arthritis mutilans) in which osteolysis is marked 5 A spondylitic form in which sacroiliitis and spinal involvement predominate; 50% of these patients are HLA-B27-positive
Prognosis
Almost all patients have persistent symptoms over decades; rare individuals experience long-term remissions The severity of disease varies greatly, with about 10% of patients having work disability after 10 years Developing hip disease within the first 2 years of disease onset presages a worse prognosis The availability of TNF inhibitors has improved the outlook dramatically for many patients with ankylosing spondylitis, and the early use of these therapies may attenuate many of the long-term disabilities otherwise characteristic of this disease
Baraliakos X et al Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis before and after therapy with the tumor necrosis factor alpha receptor fusion protein etanercept Arthritis Rheum 2005 Apr;52 (4):1216 23 [PMID: 15818694] Braun J et al Persistent clinical response to the anti-TNF-alpha antibody infliximab in patients with ankylosing spondylitis over 3 years Rheumatology (Oxford) 2005 May;44(5):670 6 [PMID: 15757965] van der Heijde D et al Infliximab improves productivity and reduces workday loss in patients with ankylosing spondylitis: results from a randomized, placebo-controlled trial Arthritis Rheum 2006 Aug 15;55(4):569 74 [PMID: 16874778] Wanders A et al Nonsteroidal antiinflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis: A randomized clinical trial Arthritis Rheum 2005 Jun; 52(6):1756 65 [PMID: 15934081]
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