Ask the Expert: Focus on Ankylosing Spondylitis

David G. Borenstein, MD recently answered your questions on ankylosing spondylitis (AS) in TheSpineCommunity. TheSpineCommunity is an online support community for individuals affected with conditions of the spine, join the conversation here.

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Is there a difference in effectiveness between oral and intravenous Methotrexate?

The question of effectiveness between the forms of methotrexate, oral and intramuscular (not intravenous), has to do with absorption of the drug. At a cellular level, oral and IM methotrexate work the same to decrease the number of cells, particularly lymphocytes. The gastrointestinal system's ability to absorb methotrexate tends to level off the higher the dose. Oral methotrexate is given once a week, at once or over a 24 hour period to limit liver toxicity. The dose for rheumatic disease patients is between 2.5 mg to 25 mg. As doses go beyond 15 to 20 mg, the concentration of drug in the blood stream tends to level off. The full concentration of methotrexate is achieved with the injection of the IM form of the drug. In addition, oral methotrexate may cause significant gastrointestinal upset including nausea and vomiting. Many individuals are able to use the IM form without developing the same degree of gastrointestinal symptoms.

Does physical therapy help with arthritis in the back?

The short answer to this question is yes. The longer answer is more complicated. There is more than 1 form of back pain. These are over 60 types of problems that can cause back pain. There is more than one way for physical therapy to help with these multiple forms of back pain. A physical therapist will try to determine the specific cause of an individual's pain and will generate a treatment plan to improve an individual's function. To learn more about back pain and the therapies for this problem go to thespinecommunity.com

Can arthritis be cured?

Arthritis means “joint inflammation” of which there are many causes. Some are curable and most can be managed effectively once correctly diagnosed. Rheumatologists are doctors that specialize in diagnosis and managing arthritis. Here is a good place to start and consider being seen by one of these experts.

I have Reactive Arthritis from an infection and chronic back pain and eye problems. At the moment I have Uveitis in the eyes from Reactive Arthritis. I would like to know what to use to clear up my eye problem?

Reactive arthritis is a form of spondyloarthritis that may effect the spine and other parts of the body including the eyes. The usual involvement with reactive arthritis is conjunctivitis which is the outer covering of the eye. Where it gets complicated is that may individuals with reactive arthritis are HLA-B27 positive. This genetic factor is associated with inflammation of an inner layer of the eye which is associated with uveitis. Conjunctivitis and uveitis are not the same. Uveitis usually requires corticosteroid drops prescribed by an ophthalmologist. Uveitis needs to be followed carefully so that eye damage does not occur. If drops do not resolve the problem, biologic agents like Humira may be needed to control the eye inflammation.

Question:  Has anyone found relief with steroid injections for the SI joints? Temporary solution, I know. Willing to try anything at this point.

The answer is yes, some patients who have had SI joint injections as a temporizing intervention can relive pain while other therapies are starting to work. When the SI joint is the only remaining active joint,  the injection is used with the expectation that is will bring control of the process like the other joints. The injection however does not last and this usually means that a change in the overall therapy is necessary for better control.

Question: Has anyone compared the TNF inhibitors to the IL-17 inhibitors? Is one better than the other?

Dr. Borenstein: No comparative studies have been completed looking at the relative benefit of tumor necrosis factor antibodies (TNFs) versus anti –IL17 antibodies.

Both categories of biologics are effective in patients with ankylosing spondylitis, psoriasis, and psoriatic arthritis. The usual sequence of drugs on an historical basis is from anti TNFs to anti-IL17 drugs. Usually patients who fail TNFs go on to IL-17 therapy. IL-17 therapy can be effective when TNF’s have not. How many TNF’s to try before switching to anti IL-17 therapy is a discussion between the patient and the doctor. No required number of TNF’s are needed before switching to the anti-IL17 biologic.

Does anyone with AS have a problem with inflammation of the legs and feet?

Some patients with the spectrum OF SPONDYLOARTHRITIS will have an enthesitis. An enthesis is the anatomic structure that attaches tendons and ligaments to bones. Enthesitis is inflammation of this structure and is a characteristic finding in spondyloarthritis. A common location for this inflammation is the Achilles tendon and plantar fascia on the bottom of the foot including Achilles tendons and some plantar fasciitis. They usually do not get small joint arthritis of toes and fingers. That pattern suggests more Psoriatic arthritis 

Question: What are the best exercises for ankylosing spondylitis?

Dr. Borenstein: The difficulty with ankylosing spondylitis is that the skeletal structures are inflamed and try to fuse. While this inflammatory process takes place, the muscles surrounding the spine tend to shorten causing pain and limited motion. Drug therapy is used to decrease inflammation and allow the muscles to lengthen.

Any exercises that improve range of motion and strengthen muscles are thought of as being helpful. Yoga exercises try to maximize range of motion from the pelvis through the low back, chest and neck. Pilates exercises tend to strengthen core muscles. If available, a visit to a physical therapist to be sure that specific areas of limited function are treated can also be helpful.

What is most important is the dedication to doing whatever exercises over time. AS is a lifelong disease and does not take a holiday. You should not take a holiday from your exercises.

Question: I find that if I drive about 20 minutes I get acute lower back pain! Is this more likely my AS, or OA? Should I ask for MRI/x-ray?

Sitting in a car seat may not be the best place to decide if a back pain is related to a mechanical or inflammatory disorder. Most car seats are not comfortable once you have been in them for a period of time particularly in stop and go traffic. Both mechanical and inflammatory disorders may cause pain to occur over a period of time. A better way to help differentiate inflammatory from mechanical back pain is when you first get up in the morning. If you have some back stiffness that goes away in 30 minutes or less, a mechanical low back pain is more likely. If you get up stiff and remain stiff for more than 30 minutes, that is a problem more likely associated with an inflammatory disorder. Hopefully, there is a rheumatologist who is 10 minutes away from your house that you can drive to before you get stiffer that can help answer your question.

Question: I have Juvenile Arthritis Spondyloarthritis. Now in my 40’s, I am dealing with lower back and cervical spine issues. In fact, I had imaging yesterday that showed inflammation in my cervical spine. I have been on Xeljanz, but is this an indication that I may need to change treatments?

Individuals who have arthritis as children may go on to have the same illness as adults or may change into another form of inflammatory arthritis like rheumatoid arthritis. In you statement, you mention back and neck pain, but only describe inflammation in the cervical spine. That may mean that the lumbar spine was not studied, or that the cervical spine alone was inflamed and not the lumbar spine. The distinction is important because rheumatoid arthritis will preferentially affect the cervical spine without affecting the lumbar spine. If that is the case, Xeljanz is an appropriate choice and may need to be given at its highest dose for a longer period of time. If the MR inflammation is located in positions that are associated with ankylosing spondylitis, Xeljanz would not be the best choice. In those circumstance an anti-tumor necrosis factor antibody, or an anti-Il 17 antibody might be a more effective choice.

Question: I am a 32 year old woman and I delivered my second baby one year back. Ever since my delivery I have been suffering from a pain in my joints which has still not subsided. What could be the reason behind this pain?

After a delivery, your immune function tries to return to its normal levels of function. In some women, this can result in the start of autoimmune processes. Post-pregnancy can be a time that rheumatoid arthritis or systemic lupus erythematosus can start. You should be evaluated by a physician who is preferably a rheumatologist so they can evaluate your situation to determine if you have developed a generalized arthritis.

Question: Psoriatic arthritis (PSA) and ankylosing spondylitis (AS) – are they the same or different diseases? Are different therapies needed to treat these diseases?

Dr. Borenstein: PSA and AS are both diseases that can affect the spine. In AS, basically 100% of patients have involvement of the spine going from the sacroiliac joints to the neck. Only about 30 to 40% of patients with PSA have involvement of the spine. The spinal involvement in PSA may look like AS but there are difference in the involvement of joints (unilateral versus bilateral sacroiliitis, for example) that distinguishes one disease from the other.

In regard to treatment, the biologic therapies that work for AS, are approved for use in PSA. Therefore, the therapies are effective for both illnesses.

Question: What are the symptoms of iritis?

Dr. Borenstein: About 40% of patients with AS will develop iritis or uveitis. Iritis that occurs in association with AS, is twice as common in males as females. The iris is the part of the eye that gets smaller or larger depending on the amount of light entering the eye. Since the iris becomes inflamed, light entering the eye will cause the iris to move and cause significant eye pain. The eye may also become red. Decreased vision may also be associated with the onset of iritis. If left untreated, iritis can result in significant loss of vision. Treatment by an ophthalmologist with steroid drops or injections can be helpful. Anti-TNF antibodies may be effective in controlling iritis in individuals who are resistant to steroid treatment.

Question: Is there a link between AS and peripheral neuropathy and/or chronic demyelinating polyneuropathy?

Dr. Borenstein: Peripheral neuropathy and polyneuropathy are not usually associated with spondyloarthritis. On occasion, patients with ankylosing spondylitis have pseudosciatica. Pseudoscitastica mimics the nerve findings associated with a herniated disc. However, in AS, the pain down the leg is caused by irritation of the piriformis muscle that attaches to the sacroiliac joint that is inflamed with sacroiliitis. The irritated muscle contracts over the sciatic nerve that runs under the muscle. Patients experience pain that radiates down the leg in a line. Decrease in sacroiliitis usually resolves the leg pain. Peripheral neuropathy starts distally in the hands and feet and moves toward the central body. This is a different kind of problem.

Question: I have been prescribed Dilaudid for my neck and low back pain but it is not relieving my pain. I have also been diagnosed with a fracture of L5. What kind of medicine can be used as a replacement?

Dr. Borenstein: The answer to this question is complicated because the question involves two different problems. The first involves the use of chronic opioids for back pain and whether they remain effective. The second involves treatment of a fracture.

In general, opioids, like Dilaudid, have not proven to be as good at relieving pain as initially thought. These drugs are only partially effective and tend to lose their potency over time. Many patients experience no difference in pain intensity when opioids are tapered. Individuals who take opioids chronically are physically dependent on the agents independent of their analgesic effects. The amount of opioid needs to be gradually reduced to prevent withdrawal symptoms. Other general categories of drugs that may be helpful include nonsteroidal anti-inflammatory agents and anti-depressants.

A fracture of a L5 vertebral body may occur for a number of reasons, but osteoporosis is a prime candidate. If that is the case, a number of treatments are available that treat bone loss and can reverse the pain associated with a fracture. A rheumatologist or endocrinologist can help with the therapy of osteoporosis.

Question: Is there any surgical solution for a fused spine up to C7? I do not have insurance so biologic therapy is cost prohibitive.

Dr. Borenstein: Surgical therapy for a fused spine is limited to those individuals who have severe curvature (kyphosis) such that they cannot look up. In those patients, an osteotomy, a procedure where a wedge of the fused spine is removed and the spine reattached so that the curve is reduced. Otherwise, no other procedure is available that reestablishes motion of the spine.

There are data to suggest that nonsteroidal anti-inflammatory drugs may be useful in preventing calcification of the spine in patients with spondyloarthritis. Two nonsteroidal drugs, ibuprofen and naproxen, are available in over the counter forms. These drugs have pain relieving properties and are anti-inflammatory. These drugs are less expensive than biologic agents.

Can RA affect my lower back? I had a discectomy of L5 five months ago but still have an achey back and some muscles spasms in lower back on the opposite side. I also have spinal stenosis

Rheumatoid arthritis  is described as affecting the lumbar spine but only in individuals with severe disease.  Those individuals with lumbar spine involvement would have damage in other joints including the fingers, toes, wrists, elbows, shoulders, hips, knees, and ankles.  The reason for back pain in this circumstance is more likely related to problems in the lumbar spine and not a systemic autoimmune disease.  Spinal stenosis is a problem in the lumbar spine that causes more leg pain than back pain.  Discectomies result in a change in the anatomy of the lumbar spine.  The amount of tissue removed and the way it is accomplished can have a significant impact on the result of the procedure.  Leg pain is the usual reason why a discectomy is done and seems to have been accomplished.  The change in anatomy may result in an imbalance in the muscles of the back.  Physical therapy to retrain the muscles can be helpful in rebalancing back muscles to be less fatigued and painful

About Dr. Borenstein: A past President of the American College of Rheumatology and a Clinical Professor of Medicine at the George Washington University Spine Center, Dr. Borenstein currently practices with Arthritis and Rheumatism Associates (ARA). He is a Master of the American College of Rheumatology and the American College of Physicians and has been active in a number of many medical professional organizations. Dr. Borenstein has served as a consultant of lumbar spinal stenosis for the National Institutes of Health, has chaired low back pain symposia for a number of physician groups, and has lectured to the general public on behalf of the Arthritis Foundation. He is a member of the International Society for the Study of the Lumbar Spine.

The Ask the Expert Series is not intended to be a substitute for healthcare professional medical advice, diagnosis, or treatment. Speak to your healthcare provider about any questions you may have regarding your health.