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When to Try a More Aggressive Treatment for AS

If ankylosing spondylitis (AS) is still causing pain and other symptoms, you might consider switching to a biologic therapy or other DMARD.

Some people begin treatment for AS with a biologic therapy or DMARD. Others may need to switch to one of these treatments later.

Medically reviewed in September 2022

Ankylosing spondylitis (AS) is a type of inflammatory arthritis.

Inflammatory arthritis refers to a group of diseases that cause inflammation and damage in joint tissues. This occurs as a result of abnormal immune system activity, and inflammatory arthritis is sometimes described as an autoimmune disease or immune-mediated disease. Other examples of inflammatory arthritis include rheumatoid arthritis, psoriatic arthritis, and gout.

With AS, this inflammation and damage predominantly occurs in the joints of the spinal column and/or the joints that connect the spinal column to the pelvis. However, people with AS can experience arthritis symptoms in other joints as well.

There is no cure for AS, but treatment can help control disease activity, put the disease into full or partial remission, and prevent complications—like permanent damage to the spine that affects movement and posture.

AS is a different experience for every person. Likewise, treatment will be a different experience, and some people will benefit from what is described as “aggressive treatment.” Here, we look at what that term means, and what you need to know when talking to your healthcare provider.

What does “aggressive treatment” mean?”
The key components of treating AS are exercise (typically under the guidance of a physical therapist) and medication.

The term “aggressive treatment” often refers to the choice of what medication to use, and when treating inflammatory arthritis, this usually means treatment with a biologic therapy or other disease-modifying antirheumatic drug (DMARD). These medications act on the immune system, disrupting the inflammatory pathways that are damaging the joints.

These medications can be effective at controlling inflammatory conditions like AS, but they also come with a greater risk of side effects. They can also be expensive, and they may not be safe for every person to take. Like many treatment decisions, a person with AS and their healthcare provider must balance the potential risks and benefits when deciding to use one of these medications.

Some people begin treatment for AS with a biologic therapy or DMARD. Others may need to switch to one of these treatments later.

When to try a more aggressive treatment?
The decision to switch to a new treatment is a decision that can only be made under the guidance of a healthcare provider. Some factors that should be considered:

  • The severity of symptoms, including pain and stiffness.
  • If there have been any changes in symptoms or any new symptoms.
  • The results of blood tests and imaging tests.
  • How AS is impacting your quality of life, including your ability to work.
  • Any other health conditions you have in addition to AS.
  • What medications you have used in the past.
  • Insurance coverage and out-of-pocket costs for medications.

If you are not already keeping a symptom journal, now is a great time to start. Use it to keep track of your symptoms—as well as when you exercise, when you take medications, your moods, and how you feel overall. This information can be very useful when making a treatment decision.

Every symptom is worth mentioning
Some people with AS also experience arthritis symptoms in other joints—like the hips, knees, ankles, and feet. They may also experience a wide variety of symptoms that can be related to having AS—hip pain, heel pain, shoulder pain, fatigue, sleep disturbances, swelling of the fingers and toes, and gastrointestinal symptoms.

Even symptoms that are different from your typical AS symptoms are important to discuss with your healthcare providers. Inflammatory diseases like AS can affect many areas of the body, and new symptoms can indicate the need for a different approach to treatment.

Article sources open article sources

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Pooja Poudel, Amandeep Goyal, and Sarah L. Lappin. Inflammatory Arthritis. April 21, 2022.
Gina S. Perez Giraldo and Jorge G. Ortiz Garcia. Immune-Mediated Disorders Affecting the Spinal Cord and the Spine. Current Neurology and Neuroscience Reports, 2021. Vol. 21, No. 3.
UpToDate. Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics).
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Arthritis Foundation. Taming High Disease Activity in Early Ankylosing Spondylitis. 
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Onecia Benjamin, Amandeep Goyal, and Sarah L. Lappin. Disease Modifying Anti-Rheumatic Drugs (DMARD). StatPearls. July 4, 2022.
Giovanni Adami, Kenneth G. Saag, et al. Balancing benefits and risks in the era of biologics. Therapeutic Advances in Musculoskeletal Disease, 2019. Vol. 11.
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