Treating ankylosing spondylitis

Ankylosing spondylitis is an inflammatory disease of the spine, which usually starts before the age of 45 and affects around 1% of the general population. Untreated, the disease can result in complete loss of spine flexibility in some patients, because of the fusion of the spinal bones. The main complaint in a majority of patients is low-back pain, neck pain or pain in the entire spine. Since back pain is a very common problem in the community, differentiating ankylosing spondylitis from mechanical back pain (because of a disc problem or some other issue) is important, because early treatment of ankylosing spondylitis can prevent disease progression.

You should suspect that you may have ankylosing spondylitis if you have low-back pain that is persistent for more than three months; have observed that it improves with exercise, but worsens with rest; and you are under 45. You may also experience stiffness in the back when you first wake up (relieved by non-steroidal anti-inflammatory drugs). Some patients complain of deep-seated buttock pain, pain and swelling in other joints — hip, knee or ankle; inflammation of the eyes (uveitis), skin rash (psoriasis) and inflammatory bowel disease (ulcerative colitis/ Crohn’s disease).

Since, the disease is very common in young individuals, it affects people in their most productive years of life. The presence of the gene HLA-B27 increases an individual’s risk of developing the disease. An unknown environmental insult (maybe a viral infection) can trigger the inflammation in the spine. However, it is important to understand that merely having the HLA-B27 gene is not equivalent to having the disease, as 10% of unaffected individuals are also positive for HLA-B27 on routine testing.

Ankylosing spondylitis progresses slowly and patients suffer from chronic back pain during these years. There is significant loss of spinal movements resulting in a stiff spine. A majority of patients are dependent on pain killers, and hence, are at risk of developing side-effects such as hypertension, stomach ulcers and kidney impairment.

Confirmation of a diagnosis is based on the patient’s history, physical examination and a few tests. Sometimes, blood tests may indicate a high level of inflammation markers. If the disease has been developing for a few years, changes in the spine and joints are evident on X-ray. These changes are only evident in established disease. However, an MRI scan of the spine can confirm the diagnosis even in the early stages. On an average, there is a delay of 4 to 11 years before a diagnosis is made.

For decades, ankylosing spondylitis was treated with non-steroidal anti-inflammatory pain killers and physiotherapy. Despite these, the disease would progress relentlessly. The advent of ‘biologic therapy’ has revolutionised the treatment. Introduction of targeted therapy against specific chemicals - cytokines (which perpetuate inflammation) has resulted in reduction of pain/stiffness in the spine and inflammation in the joints. The benefits are far superior to that with conventional pain relievers. More importantly, we now know that long-term usage of biologic drugs can in fact stop the worsening of the disease, particularly spinal fusion, in the early stages of the disease. It also helps to reduce joint inflammation which prevents permanent damage and the need for joint replacement. Some of the common biologic drugs available in India are Etanercept, Infliximab, Adalimumab and Seckukinumab.

Despite outstanding research that has confirmed the unequivocal benefit of these drugs, they are out of reach for most patients in India, because of their prohibitive cost. Most Indian health insurance companies refuse to reimburse the cost of biologic therapies despite recommendations by specialist rheumatologists.

Currently, only patients who are eligible for certain government-funded health schemes, such as Employees’ State Insurance (ESI), Central Government Health Scheme (CGHS) along with those in the armed forces and some public sector companies, have access to biologic therapy. Other patients must fund their own treatment. For this reason, the uptake of these drugs is still restricted to about 1% to 2% of those patients who really need them.

We need greater awareness about ankylosing spondylitis amongst patients, their families, the public and healthcare providers; early referral to a qualified rheumatologist; and easy access to diagnostic tests. Medical insurance companies must approve the reimbursement of biologic drugs expenses, similar to their western counterparts. If we do this, it will play a big role in helping the treatment of this dreadful disease.

(The writer is consultant rheumatologist, Fortis Hospital, Bannerghatta road, Bengaluru)