Q&As

Here are some medical questions and responses found on the website of The Arthritis Society:

Question: I am 43 and have had ankylosing spondylitis (AS) for over 20 years. I usually get iritis once every 4 years, mostly the same eye. What are your thoughts about having laser surgery for corrective vision? I have heard that if you have arthritis, they do not like to perform this type of eye surgery. Is it best to not consider this type of surgery due to iritis and my AS?
Answer: I agree that it is not a good idea to have laser surgery to correct visual acuity because of the AS and the history of iritis. With autoimmune diseases, the risk of complications is increased and proper healing may not occur. If corticosteroid drops are needed for a flare-up of the iritis right after the procedure, the cornea might not heal properly. Corticosteroid drops could also alter the cornea and negate the benefit of the surgery.

Question: I have been diagnosed with ankylosing spondylitis and sternocostoclavicular hyperostosis. I am also morbidly obese. Would it be a practical step to have the fat surgically removed to prevent further damage?
Answer: There are no studies regarding the acceleration of damage in ankylosing spondylitis and sternocostoclavicular hyperostosis by obesity. However, obesity could further compromise the restricted chest wall expansion in ankylosing spondylitis leading to clinically significant underventillation of the lungs. By increasing pressure on weight bearing joints such as knees, hips and low back, obesity could worsen already damaged joints or hasten the onset of osteoarthritis in previously healthy joints. Obesity may restrict your mobility further and contribute to many other health problems. Weight loss is important. You should consult an expert in obesity for a weight reduction program and on the advisability of including the surgical removal of fat as part of such a program. There are anaesthetic risks as well.

Question: I have ankylosing spondylitis. I am currently 5 months pregnant and can barely walk. I have not taken any medication (I usually take Mobicox) since I began trying to conceive. I am in agony. I try to keep active by walking and have been using heat and cold to help relieve some discomfort. Is there anything else I can do?
Answer: Several of the non-steroidal anti-inflammatory drugs (NSAID’s) are safe to take during the first 6 months of pregnancy, for example, naproxen, ibuprofen, diclofenac, indomethacin and ketoprofen. However, they should be stopped in the last 6 to 8 weeks of pregnancy as they may delay labour, affect a vascular duct in the baby’s heart and prolong bleeding in the mother and baby. They can be resumed during breast–feeding since only trace amounts of these drugs appear in the breast milk. During the last trimester of pregnancy, when NSAID’s should be avoided, low doses of prednisone (a type of cortisone), 5 to 10 mg per day, could be used. The mother’s blood pressure and blood sugar occasionally rise due to the prednisone. These low doses of prednisone are also compatible with breast-feeding. It is unlikely that other measures would help apart from trying the new biologic agents like infliximab and etanercept, but experience with them during pregnancy is limited.

Question: I am a 42-year-old female with active ankylosing spondylitis (AS). My mother and maternal grandfather both died from aortic aneurysms at 56 and 49 years of age. There are several others on my father's side that have AS. Should I request to see a cardiologist given that AS occasionally damages the aorta?
Answer: Ankylosing spondylitis can lead to inflammation of the origin of the aorta where it exits from the heart. As a result, the root of the aorta can become dilated causing the aortic valve to leak (aortic insufficiency). However, aortic aneurysms are not usually associated with ankylosing spondylitis. Aortic aneurysms, in general, can run in families. Rare inherited conditions such as Marfan’s syndrome and Ehler-Danlos are associated with aneurysms. Atherosclerosis is the commonest cause of abdominal aneurysms. Risk factors for atherosclerosis are usually present: smoking, age, high blood pressure, elevated cholesterol levels. There is a family clustering of abdominal aortic aneurysms in 20% of cases. Aortic aneurysms can be associated with such congenital conditions as bicuspid aortic valve and coarctation of the aorta). Inflammation of the wall of the aorta due to infections (e.g. syphilis and other bacteria) or rheumatic diseases (e.g. Takayasu’s arteritis and giant cell arteritis) is also associated with aortic aneurysms. It appears that you inherited ankylosing spondylitis from the paternal side of your family and that aortic aneurysms run in your family on the maternal side. Because ankylosing spondylitis can cause insufficiency of the aortic valve and because there is a family history of aortic aneurysms, you should be evaluated by a cardiologist.

Question: I am 60 years old and was diagnosed 7 years ago with ankylosing spondylitis (AS). Two of my three children (36 and 37 years of age) were also diagnosed with AS. My other child does not carry the gene. I understand that today the laser beam can be extremely fine and work well on very, very minute jobs, e.g. eyes. Can keyhole laser work on the spine - gently, very gently chipping away at the calcified extra bone, thus freeing the spine?
Answer: LASER stands for Light Amplification by Stimulated Emission of Radiation. Photons (units of light energy) are emitted in a narrow beam. The light consists of a single wavelength or hue. The energy range of low level laser light lies between 1 and 500 mW (milliwatts), while for surgical lasers the energy range lies between 3000 and 10000 mW. Low-level laser therapy is the external application of red and near infrared light over injuries or wounds to improve soft tissue healing and to relieve pain and inflammation. The therapy is safe. Light is transmitted through the skin and fat under the skin. However, light waves in the near infrared ranges penetrate the deepest of all light waves in the visible spectrum--up to 30 mm (a little over one inch). There is one article in the Russian literature suggesting that external irradiation of the spine and joints in people with ankylosing spondylitis using an He-Ne laser (20 sessions) was comparable to taking indomethacin at a daily dose of 75 mg. As far as I know, surgical lasers have been used to treat mild degenerative disc disease but not ankylosing spondylitis. The process in ankylosing spondylitis is so diffuse that it would be technically impossible to insert the surgical laser into all the places involved and chip away at the extra bone. I have not heard of anyone even trying this with ordinary orthopedic surgical instruments.

Question: I have had ankylosing spondylitis (AS) for two years and have been able to slowly reduce my medication through daily exercise. Last year, I had surgery on my prostate and have been having trouble with bladder retention. I am being treated for a problem dysfunctional bladder which they are telling me could be related to my spinal cord function. Is there a relationship between AS and bladder retention?
Answer: The “cauda equina syndrome” may develop rarely after many years or decades of ankylosing spondylitis (AS). The cauda equina is the bundle of spinal nerve roots (resembling a horse's tail) that run through the lower part of the spinal canal below the first lumbar vertebra where the spinal cord ends. These nerve fibres innervate the legs, buttocks, rectal area and bladder. In AS, these fibres can be enmeshed in inflammatory scar tissue so that nerve transmission is blocked. As a result, the following symptoms can occur: the gradual onset of pain, muscle weakness and altered sensation in the legs and buttocks, and bowel and bladder dysfunction. The diagnosis is made by MRI scanning of the lower spine.

Question: I am 26-year-old male, that has had ankylosing spondylitis (AS) for 13 years but do not have B27 gene. What other genes are involved in AS? I do not respond well to NSAIDs and I have taken Pamidronate IV and received some benefit (which is gone now). I have read some medical articles regarding K. pnemoniae and mycoplasma. Are there are studies of AS patients taking antibiotics?
Answer: Antibiotics have been used in the past in Reiter’s disease which can lead to ankylosis of the spine. They are not part of the modern day arsenal for AS. Has your physician considered a biologic? You could see if it applies to your case.

Question: I was diagnosed with ankylosing spondylitis in 2002. I am 25 now and still trying to find a prescription that works for me. I am currently taking Naproxen (two 325mg) before bed, but am still waking up in the night with low back pain. My SI joint was fused the last time I went to the doctor in September 2006 and I am worried that it will start going up my spine. Is there anything I can try that will slow down the fusing in my bones?
Answer: Have you seen a rheumatologist? If not, perhaps you should ask your family physician to see one. They could jointly work to control the pain and the inflammation with non pharmaceutical and pharmaceutical therapies. Do you have an exercise program for instance? Have you stopped smoking? Do you have a weight problem? Naproxen may be given at a higher dosage and, eventually, biologics are now available for ankylosing spondylitis that does not respond to traditional measures. Do get help.

Question: I have had ankylosing spondylitis (AS) for over 25 years and it is quite severe. My rheumatologist is suggesting we try an I.V. drug called pamidronate. Are you aware of it's success rate, if any. Is it safer than other treatments for AS? How long has it been around?
Answer: Dr. Walter Maksymowych, a University of Edmonton rheumatologist who is doing research in this area, has helped me with the answer to this question. Pamidronate has been used to treat Paget’s disease of bone, osteoporosis, high calcium levels, cancer metastases to bone and multiple myeloma for about 20-25 years. Dr. Maksymowych would expect this treatment to lead to a good response in about 40% of AS patients and a partial response in perhaps an additional 20%. It is important to note that responses are usually delayed for 3-6 months. It has an excellent safety record, likely superior to currently available therapies. The commonest side-effects are transient low grade fever, fatigue, aching and nausea.

Question: I am a 29-year-old female with ankylosing spondylitis. In the last four years I have tried just about every medication (NSAID, DMARD, etc) with no success. Prednisone (moderate doses) is the only thing that has helped, but the long term use is giving me very bad side effects. I am now quite disabled and would do anything to try one of the new anti-TNF drugs. Is there any sort of Canadian drug program that would help desperate people like myself afford such new drugs?
Answer: Biologic agents, such as infliximab and etanercept, improve pain, stiffness, function and well-being in patients with ankylosing spondylitis. However, it is not known whether they can stop the long term damage in the spine or improve its range of movement. To read more about the biologics in ankylosing spondylitis, go to: http://www.arthritis.ca/look%20at%20research/cochrane%20reviews/ankylosing/biologics/longversion/default.asp?s=1
Each province in Canada has a different set of rules for funding drugs. Many will pay for theses drugs but only for certain indications e.g. for rheumatoid arthritis but not for ankylosing spondylitis. Both you and your rheumatologist should get in touch with the ministry of health in your province. The ministry should be apprised of the positive results of studies using these agents in ankylosing spondylitis. Some private extended health plans will pay for these drugs. You and your rheumatologist could plead with the drug company to release one of these drugs on compassionate grounds. A local charity or benefactor might sponsor your request. If there is a clinical study on the use of these agents in ankylosing spondylitis in an area near you, you might be eligible to enter the study. You should consider joining an advocacy group to push for government funding of these drugs for ankylosing spondylitis. You should check out groups like The Arthritis Society, the Canadian Arthritis Patient Alliance and Arthritis Consumer Experts.

Question: I was diagnosed with ankylosing spondylitis about three years ago. I was taking Bextra for the past two and a half years and it was working great when I suddenly began developing painful cankers - lots of them. After three months and after having exhausted other avenues, I stopped taking the Bextra and they went away immediately. I was then prescribed meloxicam and again, the cankers came back immediately. I am at my wits end! I have been off all medication now for a week and the cankers show no signs of leaving me. Is there anything out there I can take for my AS that won't give me cankers? Or am I having to suffer with them in order to stop the pain of the AS? My doctor just keeps changing the prescription to a different NSAID.
Answer: It should be determined that the canker sores are truly due to the NSAID’s. Canker sores can also be caused by diseases associated with ankylosing spondylitis such as Crohn’s disease, ulcerative colitis and Behcet’s disease. Other drugs, allergies (e.g. certain nuts, spices, chocolate and tomatoes) and gluten sensitive bowel disease can also cause canker sores. An allergist may help to sort this out. If the cankers are due to the NSAID’s, then they should be stopped and consideration should be given to using biological agents like infliximab or etanercept to treat the ankylosing spondylitis. You would have to consult a rheumatologist.

Question: I am a 32 year-old woman who has pain in my si joint, lower back, deep within my left buttock, and my left shoulder & neck. I am seeing a chiropractor and massage therapist right now. I run 50 miles a week and lift weights and have a very strong upper body. I stretch my back constantly, but always have tightness and pain in these locations. Sometimes, for example, I cannot lie or sit without pain. Could I have ankylosing spondylitis? Both my massage therapist and chiropractor are unsure, and my doctor usually rushes me out before I can bring it up.
Answer: You could have ankylosing spondylitis. A simple X-ray of your sacroiliac joints would show the typical changes of ankylosing spondylitis and you would feel a lot better after taking regular doses of an anti-inflammatory drug for a few days if you had ankylosing spondylitis.