What to do if you have Ankylosing spondylitis which failed or stopped having response to biologics?

Biologic drugs for Ankylosing spondylitis (AS)

Fail to respond or no relief with biologics in Ankylosing spondylitis

Ankylosing spondylitis and back pain [GFDL http:// www.gnu.org / copyleft / fdl.html, via Wikimedia Commons]

Biological drugs have changed the way ankylosing spondylitis can be treated and has improved life for many patients. However, a significant number of patients do not respond to biologic drugs.

The title question was asked by a patient who lives in India and has suffered from Ankylosing spondylitis since last eight years. He has failed all available biologics in India and continues to suffer from high disease activity state.

I suggested him following possible measures. These measures may not be proper for all scenarios. One can adopt things relatable to them or talk with their rheumatologist about trying these options. Also, these suggestions might be alternatives for those who cannot afford biologic drugs, like many in India.

1. Stop smoking for control of ankylosing spondylitis

Smoking leads to inflammation and is one of the strongest factors associated with poor response to treatment in AS patients. If you smoke, decreasing and stopping smoking might be one of the most important factor to control your disease.

2. Try a different biologic for Ankylosing spondylitis – anti-TNF vs IL-17 drug

There are two family of biologic drugs available for AS treatment. The anti – TNF family acts by decreasing TNF levels, which is a cause of inflammation in AS patients. This family has 5 drugs. Secukinumab is a new family drug, which decreases  IL-17, another cause of inflammation. Many AS patients failing to anti-TNF family drugs might respond to secukinumab.

For long, we have had five biologics for Ankylosing spondylitis. They are Etanercept (Enbrel), Adalimumab (Humira, Exemptia), Certolizumab pegol (Cimzia), Golimumab (Simponi) and Infliximab (Remicade)

All these drugs decrease TNF, which is a cause of inflammation in AS patients. Though all are of same family, if one fails, there is a 30 % chance you might still respond to other. Being of same family has issues too.  If one group of this family fails, there are chances that others might fail too.

Fortunately, we now have a different family of biologics. They are IL-17 inhibitors. They work by decreasing IL 17 to reduce inflammation in patients of AS. Secukinumab (Cosentyx) , a drug of this family, has been approved in India and most other parts of the world. This tends to work in patients with failures to anti- TNF family of drugs.

Some patients have even failed secukinumab. For them, other measures mentioned here might be useful. We might also have more members added to IL 17 family or new drugs coming in the near future.

3. Higher dose of a biologic

For few patients, some biologics work in higher doses.   Sometimes antibodies form after long-term use of these drugs which decreases their efficacy. This  can be overcome by increasing the dose or changing to a different biologic as described above. You can discuss this with your rheumatologist.

4. Physiotherapy and swimming

Stopping smoking and chosing a good exercise regimen can go a long way in decreasing inflammation, pain and long-term deformities in patients with Ankylosing spondylitis

A good physiotherapist and proper exercise regimen is very important in decreasing pain, stiffness and preventing hunching associated with AS.  Swimming can make exercising easier and be an excellent substitute for many.

Surya-namaskar (sun salutation) is a 12 step exercise regimen in yoga. Surya-namaskar’s breathing and stretching components can help many AS patients.

5. Get steroid injections into active joints

Steroid injection in joints do not have much side effects as their effect is mostly limited to joints

In many AS patients its other joints like knee, shoulder, hip, ankle, etc which are more active and painful. If active, one can get these joints injected with steroids by their rheumatologist at regular intervals, without much harm.

6. Use low dose painkillers more often, for pain and inflammation of Ankylosing spondylitis  

Painkillers are actually anti-inflammatory drugs. They decrease pain by decreasing inflammation. Low dose painkillers have shown to be safe over long-term in AS patients. If nothing else works, why not take them under guidance and have a better life with less pain and inflammation ?
The following are some other measures to help AS patients, they don’t have great evidence to support them, but they might be helpful for many.

7. Try a muscle relaxant drug

In some patients, muscle relaxant drugs like chlorzoxazone (Lorzone), metaxalone (Flexura) or methcarbamol (Robaxin) can help decrease associated muscle stiffness and decrease back pain.

8. Use of steroids  systemically (other than joint injections)

Steroids if taken often in any form other than joint injections, can cause significant side effects. But, it remains only option in some patients who fail everything. In countries like India, where many patients are not able to afford biologics, this remains only option at times. If used intermittently and judiciously in low doses , steroid side effects can be minimised in these patients.

9. Try meditation exercises for ankylosing spondylitis 

It can lead to acceptance of disease, decrease stress, modulate pain pathways and can help to decrease pain.

10. Use neuromodulators for pain

Drugs like Gabapentin, Pregabalin (Lyrica) or Amitryptiline, despite not being painkillers, can modulate and decrease pain.  You can ask your doctor to consider trying one of them.

11. Methotrexate and Sulfasalazine in Ankylosing spondylitis

Though these two drugs have not shown to be effective for spine pain in AS patients, they have been used in past with reasonable benefits in some patients. They might be helpful particularly if you have active AS disease in joints other than spine.
Do let us know if any of these helps you. This might be useful for us to guide other patients accordingly.
You can refer to following link to understand more about ankylosing spondylitis :

Anylosing spondylitis explained in hindi


Author: Dr Nilesh Nolkha, Rheumatologist

Dr Nilesh Nolkha is a young and dynamic rheumatologist who keeps patients interests at forefront of everything he does.

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