Ankylosing Spondylitis

What is Ankylosing Spondylitis?

Ankylosing spondylitis (AS) is a type of inflammatory arthritis that mainly affects the spine and the sacroiliac joints, which connect the lower spine to the pelvis. It causes long-term inflammation, leading to back pain, stiffness and reduced flexibility.

In some people, ongoing inflammation may cause new bone formation, which can make parts of the spine less flexible over time.

What are the Types of Ankylosing Spondylitis?

There are two types of ankylosing spondylitis:

How Common is Ankylosing Spondylitis in India?

Ankylosing spondylitis is a chronic illness that affects approximately 16.5 lakh people in India, according to hospital-based estimates. It is considered underdiagnosed in India due to a lack of awareness, which contributes to a relatively lower number. This situation mainly arises because people may mistake early symptoms, such as chronic back pain and stiffness, for common mechanical back pain.

Moreover, delayed specialist consultation and early X-rays that appear normal can also delay diagnosis. MRI, inflammatory markers, HLA-B27 testing, clinical examination and medical history may help doctors identify the condition earlier.

What are the Symptoms of Ankylosing Spondylitis?

The symptoms of ankylosing spondylitis generally start to appear gradually and can deteriorate if treatment is not initiated in time. Early symptoms are related to the lower back and sacroiliac joints.

Common early warning signs and advanced stage symptoms of ankylosing spondylitis include:

What are the Causes of Ankylosing Spondylitis?

The exact cause of ankylosing spondylitis is not fully known. Doctors usually suspect the condition to develop due to a combination of genetic, immune system and environmental factors. These include:

• Genetic Factors: The HLA-B27 gene is strongly linked with ankylosing spondylitis, but not everyone with this gene develops the condition.

• Immune System Activity: Abnormal immune activity may cause inflammation in the spine, sacroiliac joints and other areas.

• Environmental Triggers: Many experts believe external factors, such as an undiagnosed bacterial infection or environmental stressor, act as "triggers" in genetically vulnerable people.

Risk Factors of AS

• Family History: The risk is higher for people with a close family member who has ankylosing spondylitis or related spondyloarthritis.

• Age: Symptoms often begin in late adolescence or early adulthood, typically before age 40.

• Gender: AS has traditionally been diagnosed more often in men, though women can also develop the condition and may have different symptom patterns.

Progression Phases of Ankylosing Spondylitis

Ankylosing spondylitis does not have clinically assigned medical stages but rather progression phases based on symptom severity, inflammation and changes in the spine.

The table for the progression phases of ankylosing spondylitis is given below:

Diseases Similar to Ankylosing Spondylitis

People may often confuse ankylosing spondylitis with other diseases like psoriatic arthritis with spinal involvement or reactive arthritis. These conditions often affect the spine and cause back pain. However, they are distinct in their occurrence, the locations they affect and the associated treatment outlook.

The table differentiates these three conditions for better understanding:

What are the Complications of Ankylosing Spondylitis?

Prolonged ankylosing spondylitis without timely treatment can affect the spine and may also impact other organs in rare cases. Some of the complications associated with AS include:

• Spinal Fusion: Long-term inflammation may lead to new bone formation, causing parts of the spine to become stiff or fused.

• Reduced Chest Expansion: Involvement of the rib joints may make deep breathing difficult.

• Uveitis: Eye inflammation can cause redness, pain, light sensitivity and blurred vision.

• Osteoporosis and Fractures: Spinal bones may become weak, increasing the risk of fractures.

• Hip or Shoulder Involvement: Some people may develop pain and stiffness in large joints.

• Heart Problems: Rarely, ankylosing spondylitis may affect the aorta or heart valves.

• Nerve-Related Complications: Severe spinal changes may rarely affect nerves and cause neurological symptoms.

When Should I See a Healthcare Provider?

You should see your healthcare provider if you have lower back or buttock pain lasting for more than three months, especially if the pain is worse in the morning, improves with movement or does not improve with rest.

You should also seek medical advice if you experience the following ankylosing spondylitis signs:

• Persistent lower back pain or stiffness

• Pain that improves with exercise but worsens with rest

• Morning stiffness lasting more than 30 minutes

• Pain in the buttocks, hips or heels

• Reduced flexibility or difficulty bending the spine

• Symptoms starting before the age of 40

• Repeated flare-ups that affect work, sleep or daily activities

• Red, painful eyes, blurred vision or sensitivity to light, which may suggest uveitis

• Chest tightness or difficulty taking deep breaths due to reduced chest expansion

• Family history of ankylosing spondylitis or related arthritis

How is Ankylosing Spondylitis Diagnosed?

Your healthcare provider may inquire about your symptoms, family history and medical history to identify ankylosing spondylitis. To assess your posture, flexibility and any areas of pain or stiffness, your healthcare provider may also do a physical examination.

The doctor may conduct the following tests to make a diagnosis:

Diagnostic Overview Table

How is Ankylosing Spondylitis Managed?

Your doctor may recommend therapies to manage your symptoms and lessen their impact. Some frequently recommended treatments to manage ankylosing spondylitis include:

• Exercise and Physiotherapy: Regular stretching, posture training, breathing exercises and strengthening exercises help maintain spinal flexibility and reduce stiffness.

• NSAIDs: NSAIDs may help reduce pain and inflammation.

• Biologic Medicines: These may be prescribed for moderate to severe ankylosing spondylitis when NSAIDs do not work.

• JAK Inhibitors: These may be used in selected adults with active ankylosing spondylitis under specialist supervision.

• DMARDs: These may help if peripheral joints, such as knees or ankles, are affected, but they are less useful for spine-only disease.

• Steroid Injections: These injections may be used for selected inflamed joints.

• Surgery: Surgery is rarely needed but may be considered for severe hip damage or major spinal deformity.

Common Medicines Used to Treat Ankylosing Spondylitis

Medications for ankylosing spondylitis are aimed at reducing pain, controlling inflammation, improving mobility, and slowing disease progression. However, managing ankylosing spondylitis depends entirely on the symptoms, severity, overall well-being, and the individual's response to medication.

The doctor may prescribe the following medicines to treat ankylosing spondylitis:

• Ibuprofen, Naproxen or Diclofenac: These NSAIDs help reduce pain, stiffness and inflammation.

• Celecoxib: This COX-2-selective NSAID may be used in selected patients to reduce pain and inflammation.

• Sulfasalazine: This DMARD may be useful when AS affects peripheral joints such as the knees, ankles or shoulders.

• Adalimumab, Etanercept or Infliximab: These TNF inhibitors may be prescribed for active AS when NSAIDs do not control symptoms adequately.

• Secukinumab or Ixekizumab: This IL-17 inhibitor may be used in active AS, especially when TNF inhibitors are unsuitable or not effective.

• Upadacitinib or Tofacitinib: These JAK inhibitors may be considered in selected adults with active AS under specialist supervision.

• Corticosteroid Injections: Steroid injections may be used for selected inflamed joints, but long-term oral steroids are not usually preferred for spine-related symptoms.

Note: These medicines should be taken only under the guidance of a rheumatologist. Biologics and JAK inhibitors may require screening and monitoring for infections and other side effects.

Living with Ankylosing Spondylitis: Challenges and Caregiving

Ankylosing spondylitis can hamper mobility, employment and quality of life of patients. AS patients often require continued medical care, lifestyle adjustments and support from family members to improve treatment outcomes.

Common challenges faced by patients and care points for family members include:

What is the Prognosis for Ankylosing Spondylitis?

The prognosis for ankylosing spondylitis varies depending on disease severity, time of diagnosis, response to treatment and existing complications. AS is a lifelong condition, but many people can manage the condition with medicines, regular exercise, physiotherapy and routine follow-up care.

Some patients may have periods of remission, while others may experience flare-ups. Early treatment can help reduce pain, maintain mobility and lower the risk of long-term spinal stiffness or joint damage.

How Can I Prevent Ankylosing Spondylitis?

Clinically, the cause of ankylosing spondylitis is not known, except that genetic factors may play a role in people getting the condition. However, people can take the following steps to control symptoms, reduce the risk of developing the condition or slow the progression of AS:

• Avoid tobacco products and smoking.

• Maintain a healthy weight.

• Eat a balanced and anti-inflammatory diet.

• Exercise consistently.

• Go for health checkups frequently.

• Attend regular rheumatology follow-ups.

• Report eye pain, worsening stiffness or new symptoms early.

Treatment Cost of Ankylosing Spondylitis in India

An estimate of the cost range of AS medications, therapies and surgeries is listed in the table below:

Note: The costs mentioned are approximate ranges and may vary across different locations and hospitals in India. Consult your doctor to determine the exact costs of ankylosing spondylitis treatment in India.

Does Health Insurance Cover Ankylosing Spondylitis in India?

Yes, most health insurance plans in India cover ankylosing spondylitis treatment. Coverage often includes day care procedures, hospitalisation costs, diagnostic tests, biologic therapy costs and other required medical procedures, depending on the available benefits and chosen riders and add-ons of the plan.

Ankylosing spondylitis is a chronic immune-mediated disease. If diagnosed prior to purchasing a policy, it is considered a pre-existing condition and a waiting period of up to 3 years may apply. Coverage details vary between insurers. Therefore, it is important to review policy documents carefully before making decisions.

How Much Health Insurance Coverage Is Needed for Ankylosing Spondylitis Treatment?

Ankylosing spondylitis treatment usually includes diagnostic testing, advanced medications and physiotherapy. Generally, a health insurance cover of ₹5 lakh - ₹10 lakh should cover most treatment costs for ankylosing spondylitis.

However, patients with advanced-stage ankylosing spondylitis, who may require hip replacement or spine correction surgery, may find higher insurance coverage of around ₹15 - ₹20 lakh more useful. The added coverage amount can help cover surgery expenses, hospitalisation costs and other associated expenses.

Coverage exclusions and inclusions depend on the plan and insurer. It is best to compare insurance plans to determine suitable coverage for your needs more effectively.