Ankylosing spondylitis roadmap

Symptoms

You experience back pain that gets better with activity and worse with rest, for example during sleep or when first getting out of bed in the morning. Symptoms may also include:

• joint pain
• pain where tendons or ligaments attach to bone
• other conditions such as psoriasis (a skin condition), eye inflammation and inflammatory bowel disease (IBD).

Your symptoms are likely to have started before you were 45 years old.

GP visit

You visit your GP who will ask about your symptoms, perform a physical examination and order blood tests and X-rays.

Referral to a rheumatologist

Your GP refers you to a rheumatologist (specialist bone and joint doctor) for early diagnosis and treatment if they

suspect inflammatory arthritis. Starting treatment in the early stages of AS gives better long-term results.

You should expect to have an appointment within weeks. If there is a delay of more than a few weeks, ask your GP to contact the rheumatologist directly to request an earlier appointment.

Rheumatologist visit and tests

Your appointment with a rheumatologist will include:

• a review of your medical history, including your recent joint symptoms and family history
• a general physical examination
• an examination of your spine and joints
• referral for further blood tests and imaging (eg, X-rays, ultrasound or MRI), if required.

It can take time to identify the exact cause of your symptoms and confirm a diagnosis.

Diagnosis

You are diagnosed with ankylosing spondylitis (AS).

Initial treatment: Self-management

You start learning ways to manage your symptoms, including:

• pain management techniques, including using heat and relaxation techniques
• a healthy diet to optimise your weight and reduce inflammation
• looking after your mental health by managing stress and seeking support from a psychologist or counsellor
• talking to your family and friends about how you’re feeling and how they can help
• stopping smoking, as smoking cigarettes is associated with more severe arthritis and may make medicines less effective
• advice from allied health professionals, such as a physiotherapist, to help with your self-management.

Initial treatment: Exercise

A daily exercise and stretching program has been shown to help combat joint and spinal stiffness. Get advice from a physiotherapist for a tailored exercise program for your needs. Regular physical activity will also improve your general health and wellbeing.

Initial treatment: Medicines

Your first-line medicines begin with oral non-steroidal anti-inflammatory drugs (NSAIDs) (examples include naproxen, diclofenac, ibuprofen, meloxicam, celecoxib, and indomethacin). You may trial different NSAIDs, taken for several weeks each, to determine which is more effective for you. You can expect follow-up blood tests and frequent monitoring of spinal mobility and symptoms by your rheumatologist to assess the effectiveness and side effects of treatment.

For short-term use or flares, treatment may include:

• glucocorticoids (also known as corticosteroids) injections into joints in your arms or legs
• pain relief medicines.

Learn more about AS

You can learn more about AS through:

• Arthritis Australia
• talking to your healthcare team, which might include a rheumatologist, dermatologist, GP, physiotherapist, occupational therapist, rheumatology nurse, pharmacist, dietitian, podiatrist, or psychologist.

Follow-up visits

Visit your rheumatologist for follow-up every 3–6 months to:

• assess the status of your AS and the need to modify any of your medicines or other treatments
• perform additional blood and imaging tests, if required.

Biological or targeted medicines

Your rheumatologist can also add other medicines which work by blocking specific substances in the immune system. These are called biological medicines.

• Adalimumab (Humira)
• Certolizumab (Cimzia)
• Etanercept (Brenzys, Enbrel)
• Golimumab (Simponi)
• Infliximab (Inflectra, Remicade, Renflexis)
• Secukinumab (Cosentyx)

There are many different biological medicines, as well as biosimilar* medicines, so know which one you are using.

The cost of these medicines is subsidised by the Australian Government if you meet specific criteria.

Your medicine may be given either by injections under the skin or by infusions into a vein. You will need to be screened for tuberculosis and other infections before starting these medicines. Talk to your rheumatologist about which vaccinations are recommended before starting these medicines and which need to be avoided.

Keep up your daily exercise and stretching program and continue looking after your mental health.

You continue to visit your rheumatologist to consider the use of different biological or targeted medicines until your AS is well controlled.

Disease-modifying medicines

Your rheumatologist can start you on a disease-modifying antirheumatic drug (DMARD) if you have pain in your non-spinal joints (eg, ankles, hips, hands):

• methotrexate
• sulfasalazine

Monitoring and follow-up

Once your AS is well controlled (this is called remission or low disease activity), your rheumatologist will continue monitoring your condition regularly. Your biological or targeted medicine dose may be slowly reduced, or taken less often, after a minimum of 6 months of remission or low disease activity. Learn more about this at NPS MedicineWise www.nps.org.au/bdmards/rheumat...

Do not stop your medicines, or change how much of your medicine you take, until you first discuss it with your rheumatologist or GP. Symptoms may return if certain medicines are stopped.

Continue your daily exercise and stretching program, as well as self-management through pain management techniques and looking after your mental health.

Information about AS and treatments is available from Arthritis Australia at arthritisaustralia.com.au.

Information about medicines for AS is available from the Australian Rheumatology Association at rheumatology.org.au/patients/medication-information.asp

The information contained in this factsheet has been adapted with permission from The Arthritis Society’s Your Patient Journey.

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