Disease Description (Causes and Symptoms)
- Definition summary: A chronic inflammatory joint disease that primarily affects the spine and sacroiliac joints (sacrum–ilium joints), which may gradually lead to spinal ankylosis (bone bridging, syndesmophyte formation, etc.).
- Causes and pathophysiology: The exact cause is unknown, but genetic predisposition (particularly the association with HLA‑B27) and environmental factors act together. Inflammation begins at the intervertebral disc areas and the entheses, where spinal ligaments attach, and induces bone formation (bone bridge formation), causing joint ankylosis and deformity.
- Main symptoms:
- Chronic lower back pain (usually developing before age 40 and lasting 3 months or longer), morning stiffness, worsening with rest, and characteristic pain that improves with activity
- Pain and swelling in the sacroiliac joints (pelvis) and peripheral joints such as the hips and shoulders
- Pain and tenderness in the heels (entheses) and ribs
- Extra-articular symptoms: uveitis (eye inflammation), inflammatory bowel disease (IBD), and possible coexisting psoriasis
- Rarely, effects on the heart (aortitis → valvular disease), kidneys, and lungs (reduced breathing due to limited chest expansion)
Treatment Methods
- Treatment goals: Control pain and inflammation, delay the progression of stiffness, maintain good posture and function, and preserve quality of life
- Medication treatment
- First-line: Nonsteroidal anti-inflammatory drugs (NSAIDs) — the foundation of pain and inflammation control
- Biologics: TNF inhibitors (e.g., adalimumab, etanercept, infliximab, etc.) and IL‑17 inhibitors (e.g., secukinumab, ixekizumab) — effective for axial spondyloarthritis, particularly when disease activity is high and NSAIDs are insufficient
- Oral targeted therapy: JAK inhibitors (some drugs are approved for certain axial spondyloarthritis indications) — considered according to the latest guidelines
- Long-term systemic corticosteroid use is generally not recommended. Local steroid injections may be used for inflammation in peripheral joints or around tendons.
- Conventional synthetic DMARDs (e.g., sulfasalazine) are mainly useful for peripheral joint symptoms and have limited effects on axial spinal symptoms of axial spondyloarthritis
- Non-medication treatment
- Exercise and physical therapy: Daily stretching (spinal extension exercises), strengthening, chest expansion exercises, and breathing exercises — essential for maintaining function and correcting posture
- Posture education: Learning proper posture in daily life (correction and adjustment of the work environment)
- Smoking cessation: Smoking negatively affects disease progression and prognosis → smoking cessation is recommended
- Procedures and surgery
- Joint replacement surgery (hip replacement) may be necessary in cases of destructive joint changes or severe hip destruction
- Corrective surgery may be considered when severe spinal deformity (flexion deformity) causes significant impairment in daily functioning
- Precautions during treatment
- Infection screening, including tuberculosis (TB) and hepatitis testing, is necessary before administering biologic agents
- Check vaccination status, particularly for pneumococcal disease and influenza
- If planning pregnancy or breastfeeding, the safety of the medications being used must be confirmed
Outpatient Visit Checklist (Preparation, Records, and Example Questions)
- Items to bring
- A list of currently used medications (including prescriptions, OTC medicines, and supplements) and the times they are taken
- Results of important previous tests (X-rays, MRI, blood test values, HLA‑B27 results, etc.) and records of relevant surgeries
- Pain and symptom diary: when the pain started, how long it has lasted (particularly 3 months or longer), duration of morning stiffness, changes in symptoms with activity (improvement/worsening), and whether there is nighttime pain
- Family history (rheumatic or spinal diseases, HLA‑B27-associated diseases, psoriasis, IBD, etc.)
- Information about smoking, occupation, and exercise habits
- Items that are useful to record before the outpatient visit (to provide to the doctor)
- Pain intensity (quantified) and pain location (lumbar region, hips, legs, shoulders, etc.)
- Whether there are symptoms suggestive of uveitis, such as eye redness or pain
- Digestive symptoms (bloody stool, abdominal pain) or skin changes (psoriasis)
- Recent infections or TB exposure, and vaccination history
Examples of General Questions to Ask the Doctor
- What are the main side effects of this medication (or treatment), and what symptoms should I monitor?
- How is the activity of my disease (degree of severity) assessed (e.g., BASDAI, blood tests, etc.)?
- When should biologics (or JAK inhibitors) be considered? What problems can occur with long-term use?
- I am planning pregnancy or breastfeeding. Do I need medication adjustments or alternative treatment?
- How will vaccinations or infection screening (tuberculosis, hepatitis B, etc.) be carried out?
- What type and frequency of exercise are recommended, and what should I be careful about in daily life?
Examples of Disease-Specific Questions
- My lower back is stiff in the morning and feels better when I move. Is this pattern typical of ankylosing spondylitis?
- I am HLA‑B27 positive. Should my family members (brothers and sisters) also be tested? What measures are recommended for managing family history?