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- The treatment is guided by how active
we think the disease is.
Again, you don't necessarily have to have x-ray damage.
Again, the x-rays might be normal.
So we don't base it on that.
We do use, at Hopkins,
we will usually use international standard
ways of measuring disease activity
which means a patient will fill out forms, many forms,
but we also will do our own general assessment
of course by history and exam.
The doctor will do the history and exam
as part of the assessment.
So this big, global decision if the disease is active
will guide us to treatment.
So not everybody who has the disease
needs to be on the anti-immune medicine.
For people whose disease does not appear to be active,
treatment might just remain to be anti-inflammatory
medications and a life-long, steady program of
back strengthening, stretching, flexibility, and mobility.
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If we determine the disease is active,
the disease should be treated
and the treatment beyond anti-inflammatories
and beyond if they have failed
that means that they haven't worked,
two anti-inflammatories haven't given them comfort
and their disease still is determined to be active.
They should be given the options of
taking a biologic therapy
and the usual biologics that we start with
are anti-TNF.
TNF is a type of protein molecule
that's really important in rheumatic inflammation,
particularly in spondylitis and spondyloarthritis.
The anti-TNF include many.
There are five.
With the infusions, there are two infusion anti-TNF,
but typically it will be a self-injection medicine
such as Adalimumab, which is also called Humira.
But there are several others that can be used
and that will generally be the first biologic.
There is some current interest in looking at
another class of biologic that might
be the first to be used
and it's not an anti-TNF
and it's an aisle 17 called Secukinumab,
or Cosentyx and there is some interest
in using that perhaps as the first-line biologic.
That's also a self-injection drug.
There are other biologics if these can't be tolerated,
or if there are major side effects,
or if they don't work.
There are other, newer classes of biologics
that are currently used.
There's Ustekinumab, which is Stelara,
and then there are others that are used
somewhat more in the peripheral Spondyloarthritis.
Those folks who might have more peripheral,
outer-joint arthritis, but may be used in spine
and those second-line or third-line biologics
might include Apremilast, which is Otezla
and Ixekizumab which is another class of biologic
which is used primarily for psoriatic arthritis.
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So, the biologics would be the medications to be used
in addition to regular anti-inflammatories
and a steady program of stretching and flexibility.
Now, unlike rheumatoid arthritis,
spondyloarthritis and ankylosing spondylitis
really, it should be a very important
feature of treatment is, this flexibility program.
This stretching and mobility.
Gentle yoga is very good.
Very often we'll send patients to physical therapy
at least once or twice for self-instruction
because this should become a life-long,
regular program because the hallmark
of this disease is not just pain,
but is stiffness and as I have mentioned earlier,
it continues to progress.
The progression might lead to a very stiff spine
and it can be overcome to some extent
by keeping mobile, by keeping flexible,
and that can be done every day if possible
and we want patients to understand
that it's part of the treatment.
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