Biologics have revolutionized the world of medicine ever since they arrived on the market. Biologics are today being used for treating a wide variety of conditions, one of which is ankylosing spondylitis (AS). Ankylosing spondylitis is a type of chronic autoimmune disease that impacts the hips and spinal joints (1). Inflammation that occurs in ankylosing spondylitis causes the fusing of the joints in certain parts or sections of the spinal cord (2). This fusing leads to swelling, pain, and stiffness (2). There is no cure for ankylosing spondylitis, but biologics has made it possible to efficiently manage the symptoms of this disease. Treating ankylosing spondylitis with biologics has helped many patients live a better quality of life and we take a look at exactly how biologics help in ankylosing spondylitis.
Understanding Ankylosing Spondylitis
Ankylosing spondylitis (AS) is an autoimmune condition that is known to impact the hips and spinal joints, causing certain sections of the spine to fuse together. This fusing causes pain, stiffness and swelling. The fusing of the spinal sections happens due to inflammation, which is one of the typical symptoms of an autoimmune disorder and is caused due to the immune system attacking the body. Pain, stiffness, and other symptoms of ankylosing spondylitis affect a person’s mobility, making it difficult for them to carry out even day-to-day tasks.
There is no cure for ankylosing spondylitis, but many types of treatments are available that help slows down the progression of the disease and also help manage the symptoms, allowing you to live an active and better quality of life (3). The exact treatment plan of ankylosing spondylitis is determined by your doctor only after seeing your diagnosis and your individual symptoms and severity of these symptoms.
Symptoms of ankylosing spondylitis typical range from being mild to severe and some people are able to manage their symptoms with the help of NSAIDs (nonsteroidal anti-inflammatory drugs) and this is the first line of treatment and include (4):
- naproxen sodium (brand name Aleve)
- ibuprofen (brand name Motrin and Advil)
Some examples of prescription NSAIDs include:
If you find that your ankylosing spondylitis symptoms are not coming under control with NSAIDs, your doctor will then move onto the next line of treatment, that is prescription medications. Prescription drugs that are used for controlling ankylosing spondylitis include DMARDs (disease-modifying anti-rheumatic drugs). DMARDs are known to decrease the level of inflammation in the body, but at the same time, they also lower the strength of your immune system, leaving you exposed and susceptible to infections and other diseases.
Some of the commonly used DMARDs include:
- minocycline (brand name Minocin)
- methotrexate (brand name Trexall)
- leflunomide (brand name Arava)
- sulfasalazine (brand name Azulfidine)
- hydroxychloroquine (brand name Plaquenil)
DMARDs and NSAIDs are both medications that have been designed to lower inflammation, but these drugs are unable to target the specific cause of this inflammation occurring in ankylosing spondylitis. It happens many times that the pain and stiffness resulting from ankylosing spondylitis stops responding to NSAIDs and DMARDs. In this case, your doctor may then recommend that you try out a different type of treatment known as biologics.
Biologics for Ankylosing Spondylitis
Biologics have become an extremely popular mode of treatment for many diseases in recent years. Biologic drugs are actually genetically engineered proteins that are produced from living organisms. These drugs mimic the normal biological functions. Biologics are a type of target therapy that aims at certain proteins present in the immune system that are known to create inflation (5). These proteins generally are interleukin 17 (IL-17) and tumor necrosis factor (TNF) (5).
One of the first biologic that was approved by the US FDA (Food and Drug Administration) was in the year 1988 for the treatment of rheumatoid arthritis. Since 1988, many other biologics have been developed and approved and today there are six major types of biologics that are approved and available for treating ankylosing spondylitis.
These biologics include:
Biologics that are IL-17 blockers:
- Brand Name: Cosentyx (secukinumab)
- Biologics that are TNF inhibitors:
- Brand Name: Remicade (infliximab)
- Brand Name: Enbrel (etanercept)
- Brand Name: Simponi and Simponi Aria (golimumab)
- Brand Name: Cimzia (certolizumab pegol)
- Brand Name: Humira (adalimumab)
How are Biologics for Treating Ankylosing Spondylitis Delivered?
Biologics need to be delivered into the tissue either just underneath the skin or deep into the muscle. Biologics are not available in oral or pill form. Biologics are delivered either through infusions or through injections. The frequency of these infusions or injections depends on which specific biologic therapy you are on. You may either receive an infusion of biologics every few months or you may need to get multiple starter injections, followed by follow-up biologics injections during the remainder of the year.
Take the example of the biologic Simponi. Simponi is administered through three starter injections; two will be given on day one of the treatment, followed by the third injection after two weeks. After this, you will need to administer one injection by yourself every four weeks.
On the other hand, take the example of Humira. If you are taking Humira, then you will need to take one injection by yourself once every other week after the initial dose of four starter injections.
Your doctor decides on how often you need the biologic therapy and you will also receive the instructions on just how to administer the injections yourself.
Be mindful that biologics do not lead to an overnight improvement of your ankylosing spondylitis symptoms, but you are likely to feel better within four to 12 weeks, sometimes even sooner depending on the severity of your symptoms. The goal of biologic treatment is to suppress your ankylosing spondylitis symptoms and slow down the progression of the disease, allowing you to carry on with your life. However, biologics are not going to cure ankylosing spondylitis.
How Do You Find The Right Biologic Drug For Ankylosing Spondylitis?
Nearly all the biologics used for treating ankylosing spondylitis work towards slowing down the progression of the disease and prevent inflammation. However, biologics do not have the same effect on everyone.
When you start the treatment of ankylosing spondylitis with biologics, your doctor is likely to put you on one type of biologic and then monitor your condition over the next three months to observe any improvement. If you do not notice any improvement in your ankylosing spondylitis symptoms within this time period, then your doctor may suggest changing over to a different biologic that has been approved for the treatment of ankylosing spondylitis. Finding the right biologic for your individual condition is a matter of trial and error. Keep in mind, though, that it is not advisable to take more than one biologic drug at any one time, as it increases the risk of infection. However, you can combine biologics with other ankylosing spondylitis medications. The key is to remain patient as it takes time to find just the right combination of drugs that will help you find relief from ankylosing spondylitis symptoms.
Side Effects of Taking Biologics for Ankylosing Spondylitis
There is always a risk of side effects with any type of medications, and the same holds true for biologics as well. Some of the typical side effects of biologic therapy may include:
- Redness at the Injection Site
- Bruising at the injection site
These side effects of biologics are generally mild and tend to go away on their own. However, if you notice symptoms such as swelling, difficulty breathing, and hives, then you need to notify your doctor at once as these are considered to be signs of an allergic reaction.
Biologics work by suppressing the immune system, making you more prone to infections and even cancer (6, 7). Before your very first biologic injection, your doctor is likely to conduct a complete blood work to check for any underlying conditions such as hepatitis B and C, tuberculosis and any other infections. If you notice any signs of infection after beginning the biologic treatment, including shortness of breath, weight loss, unusual fatigue, unintentional weight loss, fever, coughing, chills, you must notify your doctor immediately. Biologics are also known to increase the likelihood of getting blood cancers such as lymphoma (7).
Without the proper treatment, ankylosing spondylitis is going to continue to progress gradually and ultimately causes you increased stiffness and pain, making it difficult to remain mobile. If you feel that your current therapy is not working for you, then discuss other options with your doctor. Your doctor will be the right person to decide if you are an ideal candidate for biologic therapy. However, before you begin treatment for ankylosing spondylitis with biologics, make sure that you understand all your options and the risks involved with biologic therapy.
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