ANKYLOSING SPONDYLITIS

- ARUN . R
 INTRODUCTION

 Is a chronic, progressive inflammatory arthritis

primarily affecting spine and sacroiliac joints

 Causes eventual fusion of the spine

 ETIOLOGY

 Chronic inflammatory joint disease of axial

joints, especially the sacroiliac joints.
 Approx. 90% of affected individuals are
HLA-B27 positive.
 AS 3 times more frequent in men than in
women, and begins most often between ages
20 and 40.
 The risk of AS in 1st degree relatives with
HLA-B27 allele is about 20%.
PATHOPHYSIOLOGY

 Histologically a chronic synovitis causes destruction

of articular cartilage especially in the sacroiliac
joints.
 Inflammations of tendinoligamentous insertion sites
eventuates in bony outgrowths, which compound the
fibrous and bone ankyolsing producing severe spinal
immobility.
 Inflammation of vertebra

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SIGNS AND SYMPTOMS
 Early signs and symptoms may include pain and stiffness in lower
back and hips — which is often worse in the morning, at night and
after periods of inactivity.
 The pain and stiffness may progress up to spine and other joints,
such as those in hips, shoulders, knees and feet.
In advanced stages, the following signs and symptoms may develop:
 Restricted expansion of chest
 Chronic stooping
 Stiff, inflexible spine
 Fatigue
 Loss of appetite
 Weight loss
 Eye inflammation (iritis)
 Bowel inflammation
MANAGEMENT OF A.S
 GOALS OF TREATMENT

EASE PAIN
&
STIFFNESS

KEEP SPINE LIMIT EXTENT

MOBILE OF
& FLEXIBLE DEFORMITY

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 PHARMACOLOGICAL TREATMENT
Nonsteroidal anti-inflammatory drugs (NSAIDs)
 A group of drugs commonly used to treat arthritis because of
their
 analgesic (pain-killing)
 anti-inflammatory
 antipyretic (fever-reducing) properties.
 The mechanism of action of NSAIDs is the inhibition of the
enzyme cyclooxygenase, which catalyzes arachidonic acid to
prostaglandins
 Arachidonic acid is released from membrane phospholipids as
11 a response to inflammatory stimuli.
 Prostaglandins establish the inflammatory response. 
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ADVERSE EFFECTS
 Nausea
 Dyspepsia
 Ulceration / bleeding
 Diarrhea
 Salt and fluid retention
 Hypertension
 Interstitial nephritis
 Nephrotic syndrome
 Acute renal failure
II. STEROIDS

 Steroid hormones produce their physiological

effects by binding to steroid hormone receptor
proteins.
 The binding of steroid hormones to their receptors
causes changes in gene transcription and cell
function.
 Corticosteroids act on the immune system by
blocking the production of substances that
trigger allergic and inflammatory actions, such
as prostaglandins .

 The interference with white blood cell function

yields a side effect of increased susceptibility to
infection.
STEROIDS :-

Betamethasone
Cortisone
Dexamethasone
 Hydrocortisone
 Methylprednisolone
 Prednisolone
 Triamcinolone
ADVERSE EFFECTS

 Increased appetite and weight gain

 Deposits of fat in chest, face, upper back, and stomach
 Water and salt retention leading to swelling and edema
 High blood pressure
 Increased susceptibility to infection
 Stomach ulcers
 Increased sweating
 Mood swings
 Psychological problems such as depression
 Adrenal suppression
DISEASE-MODIFYING ANTIRHEUMATIC
DRUGS

 Is a category of drugs used in many autoimmune

disorders to slow down disease progression

 It causes immunosuppression

 This is usually done to prevent the body from rejecting

an organ transplant
 Methotrexate competetively and reversibly inhibits
dihydrofolate reductase (DHFR), an enzyme that is
part of the folate synthesis metabolic pathway.

 Dihydrofolate reductase catalyses the conversion of

dihydrofolate to the active tetrahydrofolate.

 Folic acid is needed for the de novo synthesis of the

nucleoside thymidine, required for DNA synthesis.

 Methotrexate, therefore, inhibits the synthesis of

DNA, RNA, and proteins.
 The mechanism of sulfasalazine is unknown though it has
two potential actions, blocking inflammation and inhibiting
the growth of bacteria.

DMARDs used are :-

Methotrexate
Sulfasalazine
Gold
Penicillamine
Hydroxychloroquine
ADVERSE EFFECTS

 Anemia
 Increased risk of bruising
 Nausea
 A small percentage of patients develop hepatitis
 The higher doses of methotrexate often used can cause
toxic effects to the rapidly-dividing cells of bone marrow
and gastrointestinal mucosa.
 Methotrexate is a highly teratogenic drug .
 IV. TUMOR NECROSIS FACTOR –
Alpha - BLOCKERS
 TNFα is a member of a group of cytokines that all
stimulate the acute phase reaction.
 It is a 185 amino acid glycoprotein peptide hormone,
cleaved from a 212 amino acid-long propeptide on the
surface of macrophages.
 Genetically it links to chromosome 7p21 in humans.
 TNFα is released by white blood cells, endothelium and
several other tissues in the course of damage, e.g. by
infection.
 Its release is stimulated by several other mediators, such as
interleukin 1 and bacterial endotoxin.
 It mediates the immune response by increasing the
transport of white blood cells to sites of inflammation.

 Inhibition of its action by etanercept / infliximab reduces

the inflammatory response which is especially useful for
treating autoimmune diseases.
TNF - α BLOCKERS – Etanercept ,Infliximab,
Adalimumab
 These drugs are used to treat autoimmune
disorders.

 The drug blocks the action of the

proinflammatory TNFα by binding to it and
preventing it from signaling the receptors for
TNFα on the surface of cells.
 ADVERSE EFFECTS

 Blood disorders

 Infections

 Lymphoma and other cancers

 Serious liver injury

 Central nervous system disorders

NON PHARMACOLOGICAL
TREATMENT
 Exercise is one of the most important activities in
managing ankylosing spondylitis.

 Exercise helps keep joints moving and reduce pain.

 A physical therapist can teach exercises to do daily.

 Range of motion exercises reduce stiffness and help

keep joints moving.

 Strengthening exercises maintain or increase the

strength of back muscles and help keep an upright
posture.
 Other activities such as swimming, walking, also
encourage good posture.

 Because ankylosing spondylitis causes stiffness in

the back may be more at risk of fracturing your
spine
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