Behterev's disease: treatment and prognosis

Treatment of Bechterew's disease has several goals - to reduce the severity of inflammation and pain, to prevent the development and progression of spinal and joint mobility disorders. With the advent of TNF-a inhibitors, a more significant goal of therapy becomes promising - to slow down the progression of the disease in general. However, convincing evidence of the implementation of such an opportunity has not yet been obtained.

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Indications for hospitalization

• The impossibility of conducting a full examination on an outpatient basis, especially when the patient’s independent mobility is impaired.
• The need to monitor the patient's condition during pulse glucocorticoid therapy or during the first infusions of infliximab (in some cases).
• Development of complete atrioventricular block (for the purpose of installing an artificial pacemaker).
• Exclusion of spinal fracture in case of persistent local increase in pain in the spine after injuries and falls.
• Carrying out surgical interventions on joints, spine or heart.

Indications for consultation with other specialists

• All patients should be consulted by a physical therapy instructor.
• If uveitis develops, an immediate consultation with an ophthalmologist is necessary.
• If aortic valve insufficiency or atrioventricular conduction disorders occur, a consultation with a cardiologist (cardiac surgeon) is indicated.
• In case of persistent, significant dysfunction of the hip and knee joints and pronounced kyphosis, consultation with an orthopedist is required.

Non-drug treatment of Bechterew's disease

A mandatory component of the treatment of Bechterew's disease is considered to be daily performance of a set of exercises aimed at maintaining the maximum possible range of motion in the spine and large joints and strengthening skeletal muscles. Patients with low activity of the process can be prescribed radon baths and mud application therapy as an additional method to reduce pain in the spine. Regular massage of the back muscles is useful.

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Drug treatment of Bechterew's disease

NSAIDs are of primary importance in the treatment of Bechterew's disease in the vast majority of patients. Indomethacin and diclofenac are used first, nimesulide and aceclofenac less often, and only in isolated cases are other NSAIDs prescribed. At the beginning of therapy, the maximum daily dose is recommended. A sufficient number of doses of the cervical remedy during the day are individually selected. In the presence of night pain and severe morning stiffness, it is advisable to take the drug separately at night. Provided that they are well tolerated and effective, NSAIDs are used constantly in an individually selected dose or (in the case of spontaneous or other treatment-induced relief of pain and stiffness) as needed.

If NSAIDs are insufficiently effective, patients with peripheral arthritis (enthesitis) are prescribed local administration of glucocorticosteroids, and if there is no improvement, sulfasalazine is used at a dose of 2-3 g / day for at least 4 months. Methotrexate, leflunomide, as well as other drugs belonging to the DMARD group (cyclosporine, hydroxychloroquine, gold salts and other drugs) are generally ineffective in the treatment of Bechterew's disease. If the clinical picture is dominated by spondylitis symptoms (severe pain, including at night, stiffness, high BASDAI index), high doses of glucocorticosteroids (methylprednisolone or dexamethasone in a single dose of 500-1000 mg or 60-120 mg, respectively) can be used intravenously by drip (infusion duration - 40-45 minutes) for 1-3 days. This treatment of Bechterew's disease is effective in most patients, and improvement is observed already on the first day of therapy, but the duration of the effect usually does not exceed 2-4 weeks. If the state of health improves for a long time (6 months or more), this treatment of Bechterew's disease can be repeated (during exacerbations).

Oral administration of glucocorticosteroids in small doses to patients with ankylosing spondylitis is usually ineffective. They are used only in acute anterior uveitis (in case of insufficient effect of local therapy), sometimes also in carditis, valvulitis, aortitis and IgA nephritis and in high fever caused by the underlying disease.

In case of persistent high activity of the process (BASDA1 index value of 40 or more), which persists despite adequate treatment of ankylosing spondylitis, or in case of its poor tolerance, especially in patients with factors of unfavorable prognosis of the disease, the administration of TNF-a inhibitors (infliximab, etc.) is indicated. Infliximab is used in a single dose of 5 mg/kg of body weight. The first three intravenous infusions are carried out at intervals of 2 and 4 weeks, and then, if the patient's condition is significantly better (reduction in pain and severity of other manifestations of inflammation, reduction in overall disease activity by at least 50%), infliximab is repeated at individually determined intervals (usually after 6-8 weeks) to maintain remission. If there is no significant improvement after the first three infusions, treatment of ankylosing spondylitis with infliximab is discontinued. The severity of the drug effect varies: significant improvement in well-being and positive dynamics of all the main manifestations of inflammation are noted in most patients, but remissions develop rarely, and discontinuation of treatment for Bechterew's disease almost always leads to a gradual exacerbation. Infliximab can have a positive effect in frequently recurring uveitis, torpid to conventional therapy. The tolerability of infliximab, the range of side effects, as well as contraindications for administration are similar to those in other diseases (for example, rheumatoid and psoriatic arthritis). Adalimumab has a comparable therapeutic effect in patients, a feature of which is the possibility of use in the form of subcutaneous injections.

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Surgical treatment of Bechterew's disease

Patients may require surgical operations on joints, especially hip joints (endoprosthetics). In case of persistent synovitis of the knee joints, synovectomy is indicated. Surgical interventions are known for severe kyphotic deformities of the spine, as well as in the case of subluxation of the median atlantoaxial joint. In patients with severe heart valve insufficiency, their prosthetics are indicated, and in case of complete atrioventricular block, the installation of an artificial pacemaker.

Further management

Ankylosing spondylitis is a chronic disease that should be monitored by both the patient and specialists. If Bechterew's disease is diagnosed, treatment should be carried out, then in most cases the prognosis is relatively favorable. A certain modification of the patient's lifestyle and physical activity is necessary. Of particular importance are special exercises to maintain maximum mobility in all parts of the spine and large joints. Exercises should be performed daily for at least 30 minutes. At the same time, it is necessary to avoid physical activity accompanied by overloading the muscles of the splint, sports. Regular swimming in the pool is useful. During sleep, it is recommended to use a hard mattress and small pillows. The workplace should be organized in such a way as to avoid slouching. Long-term wearing of corsets or the use of orthoses for the spine leads to weakening of the back muscles and is therefore not recommended. Dietary restrictions are not necessary. General measures for the prevention of acute intestinal and urogenital infections, which may worsen, should be strictly observed. If eye inflammation develops, an immediate consultation with an ophthalmologist is indicated.

Approximate periods of incapacity for work

Determined individually.

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Forecast

The course of the disease and the rate of progression are difficult to predict. Extreme variants of the course (excessively fast or very slow progression) are rarely observed, but most patients have a wave-like course, and the activity can subside spontaneously, without therapy. It has been established that the greater the degree of dysfunction of the spine and joints 10 years after the onset of the pathological process, the more severe the subsequent course. The prognosis is worse if ankylosing spondylitis develops in childhood, as well as with early (and the first years of the disease) damage to the hip joints, eyes, aorta, with the appearance of radiographic changes and dysfunction of the spine, with a weak effect of NSAIDs.

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