Ankylosing Spondylitis

Overview

2006-12-11T14:35:00.000-08:00

Definition:
Spondylitis involves inflammation of one or more vertebrae. Ankylosing spondylitis is a chronic inflammatory disease that affects the joints between the vertebrae of the spine, and the joints between the spine and the pelvis. It eventually causes the affected vertebrae to fuse or grow together.

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The spine is divided into several sections. The cervical vertebrae make up the neck. The thoracic vertebrae comprise the chest section and have ribs attached. The lumbar vertebrae are the remaining vertebrae below the last thoracic bone and the top of the sacrum. The sacral vertebrae are caged within the bones of the pelvis, and the coccyx represents the terminal vertebrae or vestigial tail.
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Cervical spondylosis is a disorder that results from abnormal growth of the bones of the neck and degeneration and mineral deposits in the cushions between the vertebrae. Progressive neck pain is a key indication of cervical spondylosis. It may be the only symptom in many cases. Examination often shows limited ability to bend the head toward the shoulders and limited ability to rotate the head. The goal of treatment is relief of pain and prevention of permanent spinal cord and nerve root injury.
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Alternative Names:
Rheumatoid spondylitis; Spondylitis; Spondylarthropathy
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Causes, incidence, and risk factors:
The cause of ankylosing spondilitis is unknown, but genetic factors seem to play a role. The disease starts with intermittent hip and/or lower-back pain that is worse at night, in the morning, or after inactivity.
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When and where this begins:
Back pain begins in the sacroiliac joint (between the pelvis and the spine) and may progress to include the lumbosacral spine and the thoracic spine (chest portion of the spine).
Pain may be eased by assuming a bent posture. Limited expansion of the chest occurs because of the involvement of the joints between the ribs. The symptoms may worsen, go into remission, or stop at any stage. With progressive disease, deterioration of bone and cartilage can lead to fusion in the spine or peripheral joints, affecting mobility. It can be extremely painful and crippling. The heart, the lungs, and the eyes may also become affected.
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The disease most frequently begins between age 20 and 40, but may begin before age 10. It affects more males than females. Risk factors include a family history of ankylosing spondylitis and male gender. About 0.21% of Americans over age 15 are affected.

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Treatment

2006-12-11T12:44:00.000-08:00

There are several ways to treat rheumatoid arthritis, but the first goal is to reduce symptoms -- joint pain, stiffness, and swelling. This can be done with drugs such as aspirin, nonsteroidal anti-inflammatories (NSAIDs), and corticosteroids.

Exercise, heat, cold, and physiotherapy also play an important role. In addition, a category of medications, referred to as disease-modifying antirheumatic drugs (DMARDs) can affect the underlying disease process in addition to reducing pain. For the past 20 years, the DMARD of choice has been methotrexate (Rheumatrex), originally developed for the treatment of various cancers. Unfortunately, it is effective in only one in three patients with rheumatoid arthritis.

More recently, a new class of drugs -- the prototype of which is Enbrel (etanercept) -- has become available. It targets and neutralizes an inflammation-causing protein called tumor necrosis factor. Patients who don't respond to methotrexate are given Enbrel, but heretofore the drugs were not usually taken together.

Another form of therapy, called Prosorba, filters the blood of patients with rheumatoid arthritis and removes the inflammatory antibodies from the circulation. Older agents such as gold therapy, antimalarial medications, a variety of biologic agents, azathioprine (Azasan), and cyclosporine (Sandimmune) may also help. When joints have been badly damaged and are painful, and the patient is crippled and immobilized, surgery may be necessary.

Arthritis Drugs: What are My Options?
Arthritis drugs have long been considered the "traditional" treatment option. Since individual response to drugs can vary and because potential side effects and adverse reactions are also a factor, finding the most effective combination of arthritis drugs can be a more difficult process than one would expect. Patients should become knowledgeable about the various arthritis drugs so they can make decisions with their doctor.

People with ankylosing spondylitis may get better results by taking NSAIDs (nonsteroidal anti-inflammatory drugs) daily as opposed to an as-needed basis. Results from a two year study, reported in Arthritis & Rheumatism (June 2005), show that ankylosing spondylitis progressed more slowly in patients taking the drugs regularly.

NSAID drug information, dosage, side effects, drug interactions, and warnings.
NSAIDs (nonsteroidal anti-inflammatory drugs) are a large class of medications used to treat arthritis pain and inflammation. There are three categories of NSAIDs: Salicylates (acetylated, such as aspirin, and non-acetylated), the traditional NSAIDs, and COX-2 selective inhibitors.

NSAIDs are among the most commonly prescribed arthritis drugs. NSAIDs work to combat arthritis by interfering with the inflammatory process.

How NSAIDs Work
The mechanism of action of NSAIDs is the inhibition of the enzyme cyclooxygenase, which catalyzes arachidonic acid to prostaglandins and leukotrienes.
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Arachidonic acid is released from membrane phospholipids as a response to inflammatory stimuli. Prostaglandins establish the inflammatory response. NSAIDs interfere with prostaglandin production by inhibiting cyclooxygenase.

This mechanism may relate to the variation in response between patients. Scientific studies have shown a correlation between concentration of the drug and effect, but do not explain the differences in individual patient responses. It is thought that the pharmacokinetic (process by which a drug is absorbed, distributed, metabolized, and eliminated) differences among the various NSAIDs may account for the variability in response.

The Enzyme Cyclooxygenase
Further research of the enzyme cyclooxygenase, also known as COX, has revealed that there are two forms, known as COX-1 and COX-2. NSAIDs affect both forms of cyclooxygenase. COX-1 is involved in maintaining healthy tissue, while COX-2 is involved in the inflammation pathway. COX-2 selective inhibitors became the newest subset of NSAIDs born of this research.
FDA Actions For All NSAIDs
In April 2005, The U.S. Food and Drug Administration announced actions which will be taken regarding the marketing of NSAIDs. The actions include changes for COX-2 inhibitors, as well as prescription and non-prescription (over-the-counter) NSAIDs. The actions by the FDA follow scrutiny of NSAIDs and COX-2 inhibitors provoked by the voluntary withdrawal of the COX-2 selective inhibitor Vioxx in September 2004.

FDA Announces Changes For All NSAIDs
Questions And Answers: FDA Regulatory Actions On COX-2 Inhibitors And NSAIDs

Other Facts About NSAIDs

Pain and inflammation sometimes occur in a circadian rhythm (daily rhythmic cycle based on a 24 hour interval). Therefore NSAIDs may be more effective at certain times.
NSAIDs can be divided into two groups: those with plasma (blood) half-lives less than 6 hours (i.e. aspirin, diclofenac, ibuprofen) and those with half-lives greater than 10 hours (i.e. diflunisal, piroxicam, and sulindac). Since it takes three to five half-lives to stabilize blood levels, NSAIDs with longer half-lives require a loading dose to be given (large dose given initially). The "half-life" is the time it takes a drug to go down to half of its initial level.
Prostaglandins, which are inhibited by NSAIDs, function in the body to protect the stomach lining, promote clotting of the blood, regulate salt and fluid balance, and maintain blood flow to the kidneys when kidney function is reduced. By decreasing prostaglandins, NSAIDs can cause stomach irritation, bleeding, fluid retention, and decreased kidney function.
Synovial fluid (joint fluid) concentrations are 60% of plasma concentrations regardless of type of NSAID or its half-life. Synovial fluid is mostly the site of action of NSAIDs.
NSAIDs are 95% albumin (protein) bound. The unbound fraction of the NSAID is increased in patients with low albumin concentrations such as in active rheumatoid arthritis and the elderly.
Since NSAIDs bind to plasma proteins they may be displaced by or may displace other plasma-bound drugs such as coumadin, methotrexate, digoxin, cyclosporine, oral antidiabetic agents, and sulfa drugs. This interaction can enhance either therapeutic or toxic effects of either drug.
Due to their different chemical properties some NSAIDs have substantial biliary (bile ducts, gallbladder) excretion (i.e. indomethacin , sulindac) and others are metabolized pre-excretion, while a few are excreted in the urine unchanged.
NSAID studies which have shown a variation in patient response attribute a lower rate of adherence to one NSAID when other NSAIDs are known to be available. The response to and preference of an NSAID may relate to more than just symptom control.
About 60% of patients will respond to any single NSAID.
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A trial period of three weeks should be given for anti-inflammatory effectiveness to be observed. About 10% of rheumatoid arthritis patients will not respond to any NSAID.
Antipyretic and anti-inflammatory effects of NSAIDs can mask the signs and symptoms of infection.
Adverse effects of NSAIDs which can occur at any time include renal (kidney) failure, hepatic (liver) dysfunction, bleeding, and gastric (stomach) ulceration.
NSAIDs (particularly indomethacin) can interfere with the pharmacologic control of hypertension and cardiac failure in patients who take beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, or diuretics.
Long-term use of NSAIDs may have a damaging effect on chondrocyte (cartilage) function.

Which NSAID Is Best?
It can not be predicted which NSAID will best serve a particular patient. No single NSAID has been proven to be superior over the others for pain relief. Once an NSAID is selected, the dosage should be increased until pain is relieved or until the maximum tolerated dose has been reached. The duration of analgesia does not always correspond with the plasma half-life of the NSAID. The patient response should be a guideline for selecting the proper dose, using the lowest dose possible to obtain pain relief.

Pain Relievers - Use Caution With Over-the-Counter Pain Relievers
All over-the-counter pain relievers should be taken with care to avoid serious problems that can occur with misuse. Certain factors can increase the risk of liver toxicity from products containing acetaminophen and the risk of GI bleeding from the use of products containing NSAIDs.

DMARDs
DMARDs (Disease-Modifying Anti-Rheumatic Drugs) have also been labeled "slow-acting anti-rheumatic drugs" (because they take weeks or months to work) and "second-line agents". However, research has shown the effectiveness of DMARDs in the treatment of rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis and the importance of early, aggressive treatment with these drugs. For some, these drugs can stop disease progression and halt joint damage.

DMARDs Include:

Arava (Leflunomide)
Auranofin (Ridaura, Oral Gold)
Azulfidine (Sulfasalazine)
Mycophenolate (CellCept)
Myochrysine (Injectable Gold)
Cyclosporine (Neoral,Sandimmune)
Cytoxan (Cyclophosphamide)
Imuran (Azathioprine)
Leukeran (Chlorambucil)
Methotrexate (Rheumatrex, Trexall)
Minocin (Minocycline)
Penicillamine (Cuprimine, Depen)
Plaquenil (Hydroxychloroquine)

More About DMARDs:
The Facts Of DMARDs
Disease-modifying anti-rheumatic drugs
RemittiveSlow-actingSecond lineDisease-modifying, anti-rheumatic drugs (DMARDs)
All of these names apply to a group of drugs essentially used as a second line of defense against rheumatoid arthritis after less potent drugs are deemed ineffective. They are also used for ankylosing spondylitis, psoriatic arthritis, lupus, and related conditions.
The drugs are considered remittive because they can slow down the disease process, though seldom lead to a complete remission. Since it may take 6 to 8 months for the drugs to evoke a response, they are viewed as slow-acting drugs and are chosen as a second line treatment option after aspirin and NSAIDs fail.

It is not exactly understood how DMARDs work.

Methotrexate For Rheumatoid Arthritis
In the 70's it was experimental. Now it's the standard treatment for RA.

Methotrexate For Rheumatoid Arthritis
In the 1940's, methotrexate was developed for leukemia therapy.
The first attempt to use it against rheumatoid arthritis was reported in 1951.
In the years that ensued, studies were conducted to determine the effectiveness and safety of methotrexate for the treatment of rheumatoid arthritis.

In the 1970's, methotrexate was considered an experimental treatment for rheumatoid arthritis, it is now an FDA-approved drug.

Intially, methotrexate was prescribed for patients who did not respond to other therapies. Patients were subsequently prescribed methotrexate when they were not helped by nonsteroidal anti-inflammatory drugs (NSAIDs) or by one of the other disease-modifying anti-rheumatic drugs (DMARDs) such as:

gold
penicillamine
plaquenil

Over the course of time, the trend for treatment of rheumatoid arthritis has gone from a conservative approach to the belief that early, aggressive treatment is imperative.

Methotrexate has since become the gold standard treatment for patients who have moderate to severe rheumatoid arthritis with pain, stiffness, swelling, and fatigue.

Treatment Schedule
Methotrexate may be taken orally in tablet form. The entire weekly dose is usually given once a week, frequently in divided doses over a 24-hour period, or it can be taken in one dose.

Methotrexate is usually prescribed in addition to other treatments, not instead of them.

To avoid possible gastrointestinal upset interfering with the patient's work week, Saturday is often chosen as the treatment day. Methotrexate can also be injected intramuscularly and this eliminates the gastrointestinal upset for many people.

Studies have indicated that methotrexate used in combination with another cytotoxic drug (i.e. Imuran, Cytoxan), or in combination with Enbrel (etanercept), may be more beneficial than methotrexate used alone for some people. Studies have also revealed than methotrexate given earlier in the course of treatment may provide a better result.

Combination Treatment For Rheumatoid Arthritis

Here's What's New
According to a report published in the Lancet, treating rheumatoid arthritis with a combination of methotrexate and Enbrel is more than twice as effective as either drug alone. Here are the data: After using both drugs for 1 year, 35 percent of 682 rheumatoid arthritis patients went into remission as compared with 13 percent of those on methotrexate alone and 16 percent taking only Enbrel. The other point to note is that all these patients had been suffering from the disease for years. It may be that starting this combination therapy sooner could slow down the rate of joint destruction and have an even greater effect.

The Bottom Line
There is no cure for rheumatoid arthritis. However, there are several different ways to reduce the joint pain, swelling, and deformity. Combining methotrexate and Enbrel, both of which affect the disease mechanism in addition to improving its symptoms, is more effective than either one alone. And the earlier this is done, the better.

How Methotrexate Works
Methotrexate is an antimetabolite. It interferes with the way cells utilize essential nutrients. As a result, methotrexate inhibits the activity of the immune system, consequently reducing inflammation. As a cytotoxic drug it may slow the rapid growth of cells in the synovial membrane that lines the joints.

Methotrexate is a potent drug and many have feared its potential toxicity and questioned its safety. Over the last decade, the drug has proved to be safer than expected. The toxic reactions have not appeared as frequently or severely as had been feared due probably to the low dosage level used for arthritis, 1/100 the amount used for cancer chemotherapy.

Methotrexate is a long-term treatment. Dramatic improvement seems to occur in patients within the first month or two. Steady improvement continues for many people over months or even years. When the drug is withdrawn, as has been done in studies, all signs of improvement disappear and a flare-up of symptoms occurs within a few weeks.

Side Effects
The most common side effect of methotrexate is nausea. The nausea from methotrexate use often disappears on its own though and may be controlled by lowering the dose or spreading the dose out.

The drug can cause hidden problems too and tests are done to monitor whether or not these problems are occurring. Complete blood counts are done since methotrexate can suppress the production of new blood cells and lead to severe forms of anemia.

Liver-chemistry profiles are done to watch for possible effects on the liver. Liver damage is among the worst potential problems since once the damage is done it is irreversible. Since most serious damage to the liver is not revealed in a blood test, a liver biopsy may be recommended periodically.

Another potential threat from methotrexate use is lung disease. Dry cough accompanied by fever and shortness of breath could indicate such a problem. Hair loss is seen in some patients. Some people who use methotrexate develop sores on their skin and inside their mouths. These are signs of a toxic reaction to the drug and its use may need to be discontinued.
According to the American College of Rheumatology, "the use of folate supplements (folic and folinic acid), which are B vitamins, can decrease side effects during methotrexate treatment."

Warnings
Women should not take methotrexate if they are pregnant or planning to become pregnant. Men planning to become fathers also are warned that the drug may cause birth defects and sterility. Methotrexate use is also ruled out for people who drink a lot of alcohol since the danger of liver cirrhosis then rises significantly.

Corticosteroids (Steroids)
Corticosteroids or glucocorticoids, often called "steroids", are potent drugs which can reduce swelling and inflammation quickly. These drugs are closely related to cortisol, a hormone produced on the cortex of the adrenal glands. They are prescribed in widely varying doses depending on the condition and goal of treatment. Used to control inflammation of the joints and organs in diseases such as rheumatoid arthritis, lupus, polymyalgia rheumatica, vasculitis, it has been determined that the potential for serious side effects increases at high doses or with longterm use. Doctors can prescribe short-term, high-dose intravenous steroids in some situations, or give shots or injections with drugs such as Triamcinolone (Kenalog) locally into a specific joint for relief.

Corticosteroids Include:
Betamethasone (Celestone)
Cortisone (Cortone)
Dexamethasone (Decadron)
Hydrocortisone (Cortef)
Methylprednisolone (Medrol)
Prednisolone (Prelone)
Prednisone (Deltasone)

More About Corticosteroids:
The Facts Of Corticosteroids
The Prednisone Quiz - True Or False?

Analgesics (Pain Killers)
Analgesics are pain relieving drugs. Controlling pain is a vital part of treating arthritis. However, unlike NSAIDs, analgesics do not relieve inflammation. Acetaminophen (Tylenol) is the most commonly used analgesic. Narcotic analgesic drugs can also be prescribed for more severe pain.

Narcotics Include:

Codeine (Tylenol#3)
Darvocet (Propoxyphene/Acetaminophen)
Darvon (Propoxyphene)
Duragesic (Fentanyl Skin Patch)
Hydromorphone (Palladone)(no longer on market)
Morphine Sulphate (MS Contin)
Oxycodone (OxyContin)
Percocet (Oxycodone/Acetaminophen)
Percodan ( Oxycodone/ Aspirin)
Talwin NX (Pentazocine/Naloxone)
Ultracet (Tramadol/Acetaminophen)
Ultram (Tramadol)
Vicodin (Hydrocodone/Acetaminophen)

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Work/Disability

2006-12-11T12:23:00.000-08:00

How To Manage Your Work Environment When You Have Arthritis
Arthritis can have a distinct impact on a person's work capabilities. People with arthritis must adapt their work situation to their disease. As the arthritis becomes more severe, more adaptation may be required.

Living With Limitations: Adaptation Is Key
Relationship With Employer Is A Factor
Various circumstances determine whether a person is able to continue working despite their arthritis. Certain factors are controllable, yet others are uncontrollable. The most critical factors obviously are the severity of the arthritis coupled with employer support. You can compensate for much of the difficulty caused by arthritis if a relationship with an employer is:

strong
communicative
respectful
honest

In contrast, a relationship with an employer or supervisor which is antagonistic or disinterested is unlikely to produce cooperative results.
Work Difficulty - Should You Be Honest?
How much information a person should offer their employer about their arthritis can be debated.
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Some people who fear losing their job choose to minimize and not divulge the whole truth about their arthritis. These people may create a facade which allows them to continue to work by:

not confessing just how bad their pain actually is
going to work when they should not
not wearing splints when they should

Other people believe maintaining a facade backfires because it diminishes the severity of the problem in the eyes of the employer.

Type Of Work Must Be Considered
A certain level of productivity is expected of any employee. The ability to complete tasks and meet deadlines becomes more difficult with increasing disability.

A large company with many employees may not be as concerned about individual productivity as a smaller company. The large company has enough people to counterbalance each other.

The exact nature of the job and what it entails will determine how much arthritis affects your job performance. A physically demanding job which involves lifting, carrying, walking, or a lot of standing would certainly be impacted more than a desk job. A job which requires physical abilities which become difficult or impossible due to the arthritis may be threatened.

Flexibility
Whether or not your job must be performed according to a schedule also is a consideration. If arthritis has caused you to miss a lot of time from work, or unexpected flares make you increasingly undependable, a job which operates on a tight schedule is incompatible with the disease.

Adapting Your Work Environment
It is possible for specific adaptations to be made in a workplace which would help maintain your productivity. Some of the adaptations may cost money. A company will be more likely to spend the necessary money if:

your work record is good
they feel you intend to stay employed by them
they feel you would be hard to replace

Changing your work environment to alter chair or desk height, changing the location of supplies, using electric staplers or pencil sharpeners, and other adaptations all serve to make work easier.

A later start-time, or a change in the lunch or break schedule also potentially make the day more workable. An occupational therapist can help assess your work area and offer valuable suggestions.

It is important to understand the Americans With Disabilities Act and to know your rights and understand the reasonable efforts your employer must make to accommodate your needs.
Problem Solving: Hone Your Problem Solving Skills
Assistive Devices & Aids

Disability
Studies have shown the impact of rheumatoid arthritis (RA) on employment. Over one half of individuals with RA who worked before the onset of the disease stop work within 10 years of diagnosis (Yelin et al.,1980). Those individuals with work autonomy and flexibility are more likely to remain in employment after the onset of RA (Yelin et al.,1980).

Individuals in professional or managerial occupations are considerably more likely to stay in employment after the onset of RA (Callahan et al., 1992). In one study in the U.S., it was revealed that men with RA had 48% and women 27% of the income of those without the disease (Mitchell et al., 1988).

Disability Benefits
SSDI / Disability - Do You Qualify?
61 Questions About Disability Services
How Is Disability Determined?

Managing Arthritis Helps To Manage Your Work
In order to continue working, you must stringently continue the course of treatment you are on to keep the arthritis as well-managed as possible. You must also be working at a job at which you can still function and be productive within your set of physical limitations. It is also imperative to have the support and understanding of employers and co-workers.

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