The Indian Rheumatology Association
The Professional Organization of Rheumatologists and other Health Professionals in India
Ankylosing Spondylitis

Who is more prone to get AS?
AS is usually diagnosed in young adults, with a peak age of onset of 20 and 30 years and it is three times more, in males than in females. Studies have shown that individual's risk of developing AS increased 5 to 16 fold if there was a first degree relative (parent, sibling, or child ) with AS. The presence of a gene called HLA-B27 could explain the risk of developing AS.

What causes it?
Though the origin of AS is still unknown, we do know a lot about how it progresses and why it causes spinal stiffening. It is now thought that it involves the body's immune system and that a triggering agent causes the disease and only in people with a genetic or inherited susceptibility.

What happens in AS?
The disease initially begins in the bone at the periphery of the joint and at the site where the ligament is attached to the bone, called as enthesis. The inflammatory cells at the periphery of the bone progressively increase resulting in the weakening of the bone and the body resist the weakening by attempting continuous new bone formation, As the disease process continues the bone may become weaker and weaker. When the inflammation finally burn out the body resond with excessive bone formation in an attempt to repair the damaged bone and in this process this calcification spreads to the ligamentous and even the discs. This finally results in fusion of the adjacent bone also called as bony ankylosis, which is the characteristic feature of the disease as the name suggests.

Symptoms
The most common symptom of AS is chronic low back pain and buttock pains. This back pain has the following characteristic: Begins in early adulthood (age 20 to 30); Gradual onset (rather than sudden onset after an acute injury); lasts longer than three months; worse after rest(for example in the morning); improved with activity; Wakes patients up in the second half of the night ; can cause morning stiffness lasting more than 30 minutes and can cause buttock pain that alternates between the left and right side. In the long term the flexibility of the back mat be reduced due to fusion. Arthritis in other joints may also occur. Enthesitis also causes pain in the elbow, heel and rib etc . Chronic inflammation may cause significant constitutional symptoms in the form low grade fever, fatigue and sometimes weight loss.

AS can affect eyes in 25% of patients. The symptoms of iritis include sudden onset of pain and redness, blurred vision.

Diagnosis
The diagnosis of AS is based upon a combination of a patient's symptoms, physical examination and imaging test. Patient with AS develop characteristic changes in the sacroiliac joints (the joint that connect the tailbone [sacrum] and large pelvic bone [llium]) and spine. These changes can be seen on x-ray images , although the changes take time to develop and may not be apparent until years after symptoms of AS begin. X-ray may be used to diagnose AS in someone whose symptoms, history and physical exam suggest AS. Magnetic resonance imaging (MRI) and computed tomography (CT scanning) are more sensitive than plain X-rays, and may be used if As is suspected but not clearly seen on X-ray .there is no blood test that definitively diagnose ankylosing spondylists, although testing for a gene. HLA-B27, can be helpful in selected groups of patients. Other blood tests, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may be used in some patients.

Management
Treatment depends on the characteristic and severity of the disease. the sheet anchor in the management is primarily therapeutic exercises, non steroid anti-inflammatory agents, and sometimes disease modifying anti-rheumatic drugs and in those not responding to the above modalities, anti tumor necrosis factor agents has shown promising results in various studies.

Exercise
The exercise consist of posture training, deep breathing, back extension and other stretching movements. The details demonstration of exercises for AS patients is available on the following websites: www.nass.co.uk/exercise.htm safety issues. To avoid developing deformities of the neck, a thin, rather than a thick pillow and prone sleeping may be recommended.

Medications
Nonsteroidal Anti-Inflammatory Drugs(NSAID) are the mainstay of treatment-NSAIDs need to be taken on regular basis and studies have shown that in the long term usage it is known to modify the course of disease also. The therapeutic efficacy of the NSAIDs can be better judged at the recommended dosages and needs at least 2 weeks of regular intake and subsequent long term intake of these medications. The most common side effect of NSAIDs is stomach upset. patient with a current or past history of stomach or small bowel (duodenal) ulcers, bleeding problems, or are on blood thinners (anticoagulants) may require antiulcer agents or other medications such as celecoxib.

Sulfasalazine is a disease – modifying antirheumatic drug, or DMARD, that may be given to slow or stop the progression of AS. This drug provides some relief of arthritis symptoms but has little effect on spinal pain and stiffness. Sulfasalazine can be discontinued if it is not effective after six months of treatment. Side effects of rash, low blood counts can also occur. Patients talking this medicine may need to have blood tests done periodically to monitor blood counts and liver function. Rarely other DMARs like methotrexate may be helpful.

In those patients not responding to NSAIDs and sulfasalazine, theraphy with Anti-tumor necrosis factor agents like infliximab, Etanercept, adalimumab may be considered after careful evaluation by a rheumatologist. These drugs proven to be very efficacious and improvement occurs within a few days to a few weeks of starting the drugs. However, these drugs are probably not very effective in stopping the progression of the disease

Steroids oral steroids is rarely necessary in the treatment of AS and in fact long term use of it may cause increase in bone loss and risk of developing early osteoporosis (weak bones). However steroid ( glucocorticoid injection into the sacroiliac joint and other joints may provide relief in patients who has not therapies.

AS patients are more prone to osteoporosis, hence regular consumption of more calcium and vitaminD can reduce the risk of bone loss. There are other medications that risk of bone loss, such as aledronate, risedronate, zolendronic acid, which can be used in appropriate situations.

Surgery
Total hip replacement, insertion of an artificial hip may be recommended in patients with AS who have severe, persistent hip pain or severely limited mobility due to hip joint arthritis. Spinal surgery-Fusion of the bones in the cervical spine may be recommended for a small number of patients who develop dislocation of these bones and to prevent spinal cord damage. Spinal corrective surgeries like Wedge osteotomy may be required in some patients with severe spinal deformities.

Preventing Complications
As the bones are weak in these patients risk of serious vertebral fractures from slips and falls potentially exists and utmost care to be taken to avoid such mishaps. Sedatives, narcotics and alcohol should be avoided as these agents increases the risk of fall and serious spinal injury. Contact sports and other high impact activities should be avoided. Smoking not only make the disease worse but also places lungs in a mechanically disadvantageous position in already deformed spinal and rib disease due to AS. Hence smoking is absolutely contraindicated in this disease.




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