Dr. Anu Daber

Dr Anu Daber Best Rheumatologist (Gold Medalist) EX- Rheumatologist (AIIMS, New Delhi) at Arthritis and Rheumatology Clinic in Gurgaon

Spondyloarthritis (or spondyloarthropathy) is the name for a family of inflammatory rheumatic diseases that cause arthritis. The most common is ankylosing spondylitis, which affects mainly the spine. Others include:

  • Reactive arthritis (formerly known as Reiter’s syndrome);
  • Psoriatic arthritis; and
  • Enteropathic arthritis/spondylitis associated with inflammatory bowel diseases (ulcerative colitis and Crohn’s disease).

Important facts

  • The main symptom (what you feel) in most patients is low back pain or pain and stiffness over the spine. This occurs most often in axial spondyloarthritis.
  • In a minority of patients, the major symptom is pain and swelling in the joints of arms and legs. This type is known as peripheral spondyloarthritis.
  • Many people with axial spondyloarthritis progress to having some degree of spinal fusion, known as ankylosing spondylitis. This more often strikes young males.
  • Nonsteroidal anti-inflammatory drugs (commonly called NSAIDs) offer symptom relief for most patients by reducing pain and swelling. Other medicines called anti-TNF drugs or TNF blockers are effective in patients who do not respond enough to NSAIDs.
  • Frequent fitness activities and back exercises are helpful.

What is spondyloarthritis?

Spondyloarthritis differs from other types of arthritis in that it involves the “entheses (enthesitis).” These sites are where ligaments and tendons attach to bones. Symptoms of the disease present in two main ways. The first is inflammation causing pain and stiffness, most often of the spine. Some forms can affect the hands and feet or arms and legs. The second type is bone destruction causing deformities of the spine and poor function of the shoulders and hips. Over time, spondylitis results in pronounced curvature of the spine called kyphosis.

What causes spondyloarthritis?

Ankylosing spondylitis is hereditary. Many genes can cause it. Up to 30 of these genes have been found. The major gene that causes this disease is HLA-B27.  The cause of enteropathic arthritis is unclear. It may be due to bacteria that enter the bowel when inflammation damages it. People with HLA-B27 are more likely to have this form of arthritis than those without the gene.

Who gets spondyloarthritis?

Ankylosing spondylitis tends to start in the teens and 20s and strikes males two to three times more often than females. Family members of affected people are at higher risk, depending partly on whether they inherited the HLA-B27 gene. There is an uneven ethnic distribution of ankylosing spondylitis. 

How is spondyloarthritis diagnosed?

Correct diagnosis requires a physician to assess the patient’s medical history and do a physical exam. The doctor also may order imaging tests or blood tests. You may need an X-ray of the sacroiliac joints, a pair of joints in the pelvis. X-ray changes of the sacroiliac joints, known as sacroiliitis, are a key sign of spondyloarthritis.  If X-rays do not show enough changes, but the symptoms are highly suspicious, your doctor might order magnetic resonance imaging, or MRI, which shows these joints better and can pick up early involvement before an X-ray can.

Among the blood tests you may need is a test for the HLA-B27 gene. However, having this gene does not mean spondyloarthritis will always develop. Some people have the HLA-B27 gene but do not have arthritis and never develop arthritis. In the end, the diagnosis relies on clinical features and the doctor’s judgment.

How is spondyloarthritis treated?

All patients should get physical therapy and do joint-directed exercises. Most recommended are exercises that promote spinal extension and mobility. There are many drug treatment options. The first lines of treatment are the NSAIDs, such as naproxen, ibuprofen, or indomethacin. No single NSAID is superior to another. Given in the correct dose and duration, these drugs give great relief for most patients. For joint swelling that is localized (not widespread), injections, or shots, of corticosteroid medications into joints or tendon sheaths (the membrane around a tendon) can be quite effective.

For patients who do not respond to the above lines of treatment, disease modifying antirheumatic drugs (commonly called DMARDs) Sulfasalazine, Methotrexate or Leflunomide might be effective. These drugs relieve symptoms and may prevent damage to the joints. This class of drugs is helpful mainly in those with arthritis that also affects the joints of the arms and legs. The spine involvement does not respond well to DMARDs. These patients require biological agents early in the course of therapy for adequate control of the disease activity. 

Antibiotics as therapy are an option only for patients with reactive arthritis.

TNF alpha blockers (a newer class of drugs known as biologics) are very effective in treating both the spinal and peripheral joint symptoms of spondyloarthritis. The approved TNF alpha blockers for use in patients with ankylosing spondylitis are:

  • Infliximab, which is given intravenously (by IV infusion) every 6-8 weeks at a dose of 5 mg/kg;
  • Etanercept, given by an injection of 50 mg under the skin once weekly;
  • Adalimumab, injected at a dose of 40 mg every other week under the skin; and
  • Golimumab, injected at a dose of 50 mg once a month under the skin.

However, antiTNF treatment is expensive and not without side effects, including an increased risk for serious infections. Biologics can cause patients with latent tuberculosis (no symptoms) to develop active tubercular infection. Therefore, you and your doctor should weigh the benefits and risks when considering treatment with biologics. Those with arthritis in the knees, ankles, elbows, wrists, hands and feet should try DMARD therapy before anti-TNF treatment. Surgical treatment is very helpful in some patients. Total hip replacement is very useful for those with hip pain and disability due to joint destruction from cartilage loss. Spinal surgery is rarely necessary, except for those with traumatic fractures (broken bones due to injury) or to correct excess flexion deformities of the neck, where the patient cannot straighten the neck.

Broader health impacts

Other problems can occur in patients with spondyloarthritis. These include:

  • Osteoporosis, which occurs in up to half of patients with ankylosing spondylitis, especially in those whose spine is fused. Osteoporosis can raise the risk of spinal fracture.
  • Inflammation of part of the eye, called uveitis, which occurs in about 40% of those with spondyloarthritis. Symptoms of uveitis include redness and pain of the eye. Steroid eye drops most often are effective, though severe cases may need other treatments from an ophthalmologist.
  • Inflammation of the aortic valve in the heart, which can occur over time in patients with spondylitis. Your doctor should check your heart to make sure you do not have this problem.
  • Psoriasis, a patchy skin disease, which if severe will need treatment by a dermatologist (skin doctor).
  • Intestinal inflammation, which may be so severe that it requires treatment by a gastroenterologist (doctor who specializes in digestive diseases).

Living with spondyloarthritis

Pain, fatigue and stiffness can be continuous or off and on. Despite these symptoms, most patients with spondyloarthritis lead productive lives and have a normal lifespan, especially with the availability of newer treatments (biological).

Frequent exercise is essential to maintain joint and heart health. If you smoke, try to quit. Smoking aggravates spondyloarthritis and can speed up the rate of spinal fusion.

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