How to Tamp Down the Inflammation

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte, the chief medical officer at WebMD. Ankylosing spondylitis is the type of arthritis that causes pain and stiffness in your spine. It typically occurs first in your lower back. It can progress to your neck and also cause destruction of joints in other parts of your body.

In medicine, we always have these complicated words but just so you know, "ankylosis" means fused bones. "Spondylitis" means inflammation of your spinal bones or vertebrae. The good news is that we have more effective treatments for ankylosing spondylitis than we ever have had before.

So helping you understand what your options are are two experts-- Dr. Marina Magrey. She's Division Chief, Rheumatology at University Hospitals Cleveland Medical Center. And Dr. Maureen Dubreuil. She's an assistant professor of Medicine at Boston University. Doctors, thanks for joining me.

Thank you so much for having us.

Good to be here.

Dr. Dubreuil, I want to start with you and talk about what are the therapeutic options for patients with ankylosing spondylitis? Let's start off with things that aren't medications. Is there role for exercise, lifestyle, diet?

So there absolutely is a role for treatments other than medications. And the treatment with the most evidence for it is exercise. Exercise is one of the mainstays of treatment for ankylosing spondylitis and axial spondyloarthritis overall.

And our recommendation is generally for people to do exercise every day or a few times per week. Generally, what I recommend for my patients is low-impact walking or stretching program. In particular, exercises focused on flexibility of the spine.

So Dr. Magrey, exercise isn't going to be enough for some people. And obviously, everyone should do that, there's lots of benefits overall. What's that next step in terms of therapeutic options, in terms of treatments?

MARINA MAGREY: So the cornerstone for treatment of ankylosing spondylitis has been non-steroidal anti-inflammatory agents. So when these patients are first seen, along with exercise, some self-care. And we prescribe nonsteroidal anti-inflammatory agents. So we give them a trial of at least four weeks on a full strength anti-inflammatory to see how much improvement that they're able to get with it.

And then what is that next form of treatment? Because some patients will say, I didn't get relief. Others will say, I got GI upset.

So the good news is there's multiple other treatments now available-- different classes of medications that are available for treatment of ankylosing spondylitis. The availability of biologics has actually revolutionized this treatment. The first biologic that became available for ankylosing spondylitis was in 2003 was etanercept.

And then, it's a TNF alpha inhibitor. So then over time, multiple other TNF inhibitors became available. And then in mid to around 2015, 2016, we got a new class of medications that's now available, which is IL-17A blockers. So we have a couple of agents in that family. So we have multiple medications now available to treat those patients who do not respond to NSAIDs.

And how are these latest treatments, Dr. Dubreuil, different than NSAIDs? Is it more targeted? More precision? How do the newer agents work?

So you're right. These new agents are more targeted in the inflammatory component that they address. So TNF inhibitors specifically inhibit TNF alpha, which is an inflammatory molecule involved in many different parts of the inflammation process.

IL-17 inhibitors, at this moment, they inhibit IL-17A, which is a specific inflammatory molecule. And thirdly, Janus kinase inhibitors, the one that's on the market for ankylosing spondylitis, inhibits a specific molecule in cell signaling pathways.

And this speaks to the cause of the disease, right? This is not arthritis where it's wear and tear degenerative disease. It's really inflammation and immune function that we're trying to reach with these targeted therapies, is that right?

That's absolutely right.

And then Dr. Magrey, what's on the horizon? Just like the next two years. You rattled off things that have been occurring, it seems like, every three or four years. Is there anything new that excites you on the horizon?

Yes, we are going to have another-- hopefully another Janus kinase inhibitor that may get approved soon. We already have seen the long-term safety and efficacy data of it. It's called baricitinib. It is another Janus kinase inhibitor.

Then we have another medication which is a dual inhibitor of IL-17A and F molecule. And that is-- studies have completed, BE MOBILE 1 and BE MOBILE 2. So expecting that should also be available soon, in the next few months. There are some early phase 2 studies starting with some other molecules. There is a molecule called HMGA2 inhibitor, which is in very early studies.

Dr. Dubreuil, is there a role for surgery at any point?

So there is a limited role for surgery. And what is recommended in terms of expert guidelines is for people who have end-stage arthritis of their hips, which is a fairly common site of involvement in ankylosing spondylitis. So for those people, hip replacement surgery is recommended.

There is a recommendation somewhat against surgery at other levels of the spine, solely for the sake of straightening the spine or fusing the spine. And so that is reserved only for people that have neurologic complications from their spinal arthritis.

Dr. Magrey, viewers watching recently diagnosed with ankylosing spondylitis has disability issues in terms of function. What's your message to them?

So I understand navigating through a chronic illness is not easy. So first and foremost, they need to find a rheumatologist who is willing to listen and is well-versed in the knowledge of the disease. The best news I can tell these patients is you're lucky to be having this disease now when we have multiple medications available which slow and also prevent some of them radiographic progression. So we may never see those patients with the bamboo spine ever again.

And we have a lot of support groups. Spondylitis Association of America is a large support group and they have lots of resources for these patients. They can talk to other patients. Learn about the disease. So it is not that they should be feeling scared or worried that this may interfere with their activities of everyday.

But as you point out, it's a chronic condition that needs to be aggressively managed because we do have a lot of treatment options today. Many more than we did just a few years ago. Doctors, I want to thank you both for joining me today.

Thank you.

Thank you so much.

If you have questions about ankylosing spondylitis, drop me a line. You can email me at [email protected]. Thanks for watching. [MUSIC PLAYING]