RISK FACTORS : FIRST DEGREE RELATIVE WITH AS INCREASES A PATIENTS RISK BY 5 TO 16 FOLDS. HLA-27 POSITIVE CHILDREN WHO HAVE SIBLINGS WITH AS HAVE A 10-20% RISK OF GETTING AS. MALES HAVE HIGHER RISK OF AS.
Medical Care: Treatment of ankylosing spondylitis is divided into medical care, physical therapy, and surgical care. Patient education is important in the management of any chronic disease so that the patient is familiar with the symptoms, course, and treatment of the disease. No drugs have been proven to modify the course of the disease, although TNF- antagonists have potential as disease-modifying agents.
" Nonsteroidal anti-inflammatory drugs
o NSAIDs improve the symptoms of the disease. Indomethacin may be more effective than other NSAIDs, although this has not been proven.
o Salicylates seldom give adequate relief. Cyclooxygenase-2 (COX-2) inhibitors appear to be as effective as nonselective NSAIDs.
o Give NSAIDs in full anti-inflammatory doses. Continuous treatment with NSAIDs appears to reduce radiographic progression in ankylosing spondylitis. Common toxicities involve the gastrointestinal (nausea, dyspepsia, ulceration, bleeding), renal, and central nervous systems.
" Sulfasalazine
o Sulfasalazine is often used in the treatment of ankylosing spondylitis and other spondyloarthropathies (SpAs), especially for peripheral joint involvement, for which it has demonstrated efficacy. Sulfasalazine has been shown to be effective in ankylosing spondylitis, particularly in reducing spinal stiffness, peripheral arthritis, and reducing the ESR, but no evidence shows that spinal mobility, enthesitis, or physical function is benefited.
o Toxicities include rash, nausea, diarrhea, and agranulocytosis (rarely).
" Other medications
o Anecdotal reports suggest that other medications are helpful in the treatment of ankylosing spondylitis, including methotrexate, azathioprine, cyclophosphamide, and cyclosporine.
o Methotrexate may have some benefit in ankylosing spondylitis, although various studies have shown conflicting results.
o The TNF- antagonists have been shown to be effective in the treatment of ankylosing spondylitis, and etanercept, infliximab, and adalimumab are approved therapies. These agents are very effective with fairly rapid onset of action (2 wk) and have been shown to reduce inflammatory activity of spinal disease as assessed with MRI.
o Bisphosphonates may modestly affect clinical disease activity in ankylosing spondylitis.
o Anakinra, a recombinant human interleukin 1 (IL-1) receptor antagonist, may be effective in treatment-resistant ankylosing spondylitis.
" Corticosteroids
o Oral corticosteroids occasionally are helpful in controlling symptoms; however, use them only for short-term management. No evidence exists that corticosteroids alter the outcome of the disease, and they increase the tendency towards spinal osteoporosis.
o Local corticosteroid injections are useful for symptomatic sacroiliitis, peripheral enthesitis, and arthritis, although the response typically is not as rapid as in patients with rheumatoid arthritis.
" Treatment of extra-articular manifestations
o Treat extra-articular manifestations as dictated by the clinical setting.
o Acute anterior uveitis presents as a painful, red eye that is associated with photophobia and often recurs. Untreated uveitis may lead to vision loss.
o Evaluation and treatment of uveitis should be delivered under the guidance of an ophthalmologist. Generally, patients respond well to topical corticosteroids, mydriatics, and artificial tears, with resolution of the attack over 2-3 months. Treatment may occasionally require topical NSAIDs, retrobulbar corticosteroid injections, or immunosuppressive drugs. TNF- antagonists may be helpful in selected cases.
Surgical Care:
" Surgery occasionally is useful to correct spinal deformities or repair damaged peripheral joints.
" Vertebral osteotomy may be performed to correct spinal deformities, but significant morbidity is related to neurologic complications of this procedure. This procedure should be performed only by surgeons specializing in spine surgery who have experience with this procedure, as the risk of major neurologic morbidity is significant.
" Patients may need total hip replacement and, occasionally, total shoulder replacement. These procedures may be very useful to reduce pain and improve function when the hip and shoulder joints become severely damaged. Heterotopic bone formation may occur after total joint replacement, especially around the hip. Heterotopic bone formation can be reduced by using postoperative NSAIDs (eg, indomethacin). In general, outcomes of total joint replacement in patients have been satisfactory.
Diet:
" No special diet is required.
Activity:
" Physical therapy
o Physical therapy, including an exercise program and postural training, is important to maintain function.
o Spinal extension and deep-breathing exercises help maintain spinal mobility, encourage erect posture, and promote chest expansion. Maintaining an erect posture during daily activities and sleeping on a firm mattress with a thin pillow also tend to reduce the tendency towards thoracic kyphosis.
o Water therapy and swimming are excellent activities to maintain mobility and fitness.
- ENCOURAGE TO STOP SMOKING DUE TO POSSIBLE LUNG ENVOLVEMENT
- PROPHYLACTIC TREATMENT FOR OSTEOPOROSIS
- ANTIBIOTIC PROPHYLAXIS IN CARDIAC VALVE ENVOLVEMENT PATIENTS.
- PAMIDRONATE & THALIDOMIDE MAY BE OF SOME BENEFIT IN MUSCULOSKELETAL SYMPTOMS.