A number of treatments are available that can ease pain and stiffness, but exercise and close attention to your posture are just as important to keep the spine mobile and help you to live a normal life.
Drugs for ankylosing spondylitis
Painkillers (analgesics) and non-steroidal anti-inflammatory drugs (NSAIDs) are usually the first choice of treatment, and most people with ankylosing spondylitis will need to take these at times.
Painkillers such as paracetamol or co-codamol are often very helpful. They can be taken regularly and are particularly useful just before activity to keep your pain to a minimum. It's best not to wait until you're in severe pain before taking them. They don't need to be taken with a meal, though some water and a small snack are advised.
There's a wide range of NSAIDs that can reduce pain so you can get on with your daily activities and your exercise routine. You'll probably need to take these during bad patches, and some people may need them over a longer period. Some tablets are made in a slow-release formulation, which can help with night-time pain and morning stiffness. Some NSAIDs are also available as gels, which you can apply to the painful area.
Like all drugs, NSAIDs can sometimes have side-effects, but your doctor will take precautions to reduce the risk of these, for example by prescribing the lowest possible dose for the shortest possible period of time.
Drugs such as sulfasalazine and methotrexate can be helpful for arthritis in the joints of your arms or legs, although they're not usually effective for spinal symptoms. These disease-modifying anti-rheumatic drugs (DMARDs) are given to reduce damage to the joints rather than just controlling pain. They’re slow-acting so you won’t notice an immediate impact, but they can make a big difference to your symptoms over a period of time.
Biological therapies (anti-TNF drugs) are newer treatments that can be very effective for ankylosing spondylitis and non-radiographic axial spondyloarthritis. A number of anti-TNF drugs are currently available for these conditions – including etanercept, adalimumab, certolizumab pegol and golimumab. They can only be prescribed by a rheumatologist and are given as an injection under your skin, which you can learn to give yourself. Biological therapies aren’t suitable for everyone and can only be prescribed if your condition can’t be controlled with anti-inflammatory drugs and physiotherapy.
The effect of anti-TNF drugs is monitored, and you'll need to complete questionnaires regularly which assess how active your disease is and how well it's responding to treatment.
Steroids can be used as a short-term treatment for flare-ups. They’re usually given as an injection into a swollen joint or as a slow-release injection into a muscle. They can also be used for painful tendons, for example at the heel, although they won't be repeated very often as this may lead to tendon weakness. Occasionally, you may be given a course of steroid tablets (prednisolone). While these treatments can be very effective at improving pain and stiffness, you may develop side-effects if you use them for long periods, for example, weight gain, bruising or thinning of the skin, high blood pressure, high blood sugar, infections or osteoporosis.
If you develop eye inflammation, it'll usually be treated with steroid eye drops. In more severe cases, steroids may be given as tablets or as an injection into the eye.
Bisphosphonates are usually used to treat osteoporosis. It's been suggested they may also help the pain and stiffness of ankylosing spondylitis, although research so far hasn't confirmed this.
Physical therapies for ankylosing spondylitis
Physiotherapy is a very important part of the treatment for ankylosing spondylitis. A physiotherapist can put together a programme of exercises that increase your muscle strength and help you maintain mobility in your spine and other joints. It’s especially important to exercise your back and neck to avoid them stiffening in a bent position.
A physiotherapist will advise you on how to maintain good posture and may also be able to offer you hydrotherapy, which involves special exercises in a warm-water pool. Many people with AS find this therapy helpful and continue their programme at their local leisure pool or with a National Ankylosing Spondylitis Society (NASS) group.
Surgery for ankylosing spondylitis
Most people with ankylosing spondylitis don’t need surgery, although some may need a hip or knee replacement if these joints are badly affected. This can get rid of pain and improve mobility. Surgery to straighten a bent spine is very rare and isn’t usually recommended. You should speak to your rheumatologist about referral to an experienced spinal surgeon if you want advice on this.