Bechterew's disease: treatment and prognosis

Treatment of Bekhterev's disease pursues several goals - to reduce the severity of inflammation and pain, to prevent the development and progression of mobility disorders of the spine and joints. With the advent of TNF-a inhibitors, the more significant goal of therapy is becoming promising-to slow the progression of the disease and the whole. However, there is no convincing evidence of the realization of this possibility.

[1], [2], [3], [4]

Indications for hospitalization

• Impossibility of conducting a full-fledged examination on an outpatient basis, especially if the patient has no independent movement.
• The need to monitor the patient's condition during pulse therapy with glucocorticoids or with the first infusions of infliximab (in some cases).
• Development of a complete atrioventricular blockade (for the purpose of installing an artificial pacemaker).
• Elimination of vertebral fracture in case of persistent local strengthening of pain in the spine after injuries and falls.
• Performing surgical interventions on the joints, spine or heart.

Indications for consultation of other specialists

• All patients should be advised by an instructor in exercise therapy.
• In the case of development of uveitis urgent consultation of the oculist is necessary.
• When aortic valve failure or atrioventricular conduction disorders appear, the consultation of a cardiologist (cardiac surgeon) is shown.
• With a persistent, significant violation of the functions of the hip, knee joints and pronounced kyphosis, orthopedic consultations are needed.

Bezkhterev's non-drug treatment

An obligatory component of the treatment of Bekhterev's disease is the daily execution of a set of exercises aimed at maintaining the maximum possible volume of movements in the spine and large joints and strengthening of skeletal muscles. Patients with low activity of the process as an additional method to reduce pain in the spine, you can appoint radon baths, application mud therapy. Regular massage of the back muscles is useful.

[5], [6], [7], [8]

Drug treatment of Bechterew's disease

The main significance in the treatment of Bekhterev's disease of the vast majority of patients are NSAIDs. Primarily, indomethacin and diclofenac are used, less often nimesulide and aceclofenac, and only in some cases other NSAIDs are prescribed. In the beginning of therapy, the maximum daily dose is recommended. Individually, a sufficient number of receptions of the cervical baker are selected during the day. In the presence of nocturnal pains and severe morning stiffness, it is advisable to take a separate preparation at night. With good tolerability and efficacy, NSAIDs are used continuously in an individually selected dose or (in the case of spontaneous or induced by other methods of treatment of stifling pain and stiffness) as needed.

With insufficient effectiveness of NSAIDs, patients with peripheral arthritis (entesitis) show local administration of glucocorticosteroids, and in the absence of 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 DMAP group (cyclosporine, hydroxychloroquine, gold salts and other medicines), in the treatment of Bechterew's disease, are usually ineffective. With the predominance of spondylitis symptoms in the clinical picture (severe pain, including stiffness, high BASDAI at night), high doses of glucocorticosteroids (methylpredniieolone or dexamethasone in a single dose, respectively, 500-1000 mg or 60-120 mg) can be applied intravenously drip (duration of infusion - 40-45 min) and for 1-3 days. This treatment for Bechterew's disease is effective in most patients, and improvement is observed on the first day of therapy, but the duration of the effect usually does not exceed 2-4 weeks. If the well-being improves for a long time (6 months or more), you can repeat this treatment for Bekhterev's disease (with exacerbations).

The administration of glucocorticosteroids inside in small doses in 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 with carditis, valvulitis, aortitis and IgA-nephritis and with a high fever due to the underlying disease.

In the case of persistent high activity of the process (the value of the BASDA1 index is 40 or more) that persists despite the adequate treatment of Bechterew's disease, or if it is poorly tolerated, especially in patients with the presence of factors of an unfavorable prognosis of the disease, the appointment of TNF-a inhibitors (infliximab and others .). Infliximab is used in a single dose of 5 mg / kg 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 (reducing the pain and severity of other manifestations of inflammation, reducing the overall activity of the disease by at least 50%), infliximab is repeated at individually set intervals usually in 6-8 weeks) to maintain remission. If no significant improvement occurs after the first three infusions, treatment with Bechterew's disease with infliximab is stopped. The severity of the effect of the drug varies: a significant improvement in well-being and positive dynamics of all major manifestations of inflammation are noted in most patients, but remissions are rare, and the cessation of treatment for Bechterew's disease almost always leads to a gradual aggravation. Infliximab may have a positive effect with a frequently recurring uveitis, torpid to conventional therapy. The tolerability of infliximab, the spectrum of adverse reactions, and contraindications to prescribing are similar to those in other diseases (for example, rheumatoid and psoriatic arthritis). Comparable therapeutic effect in patients has adalimumab, a feature of which is the possibility of using in the form of subcutaneous injections.

[9], [10], [11], [12], [13]

Surgical treatment of Bechterew's disease

Patients may have a need for surgical operations on joints, especially hip (endoprosthetics). With persistent synovitis of the knee joints, synovectomy is shown. There are known surgical procedures performed with severe kyphotic deformities of the spine, as well as in the case of subluxation of the mid-Atlantic atlas joint. Patients with severe heart valve insufficiency are shown to have their prosthetics, and with complete atrioventricular blockade - the installation of an artificial pacemaker.

Further management

Ankylosing spondylitis is a chronic disease that both the patient and specialists must control. If the diagnosis of Bechterew's disease was established, treatment should be performed, in most cases the prognosis is relatively favorable. A certain modification of the lifestyle and physical activity of the patient is necessary. Especially important are special exercises to maintain maximum mobility in all parts of the spine and large joints. Exercise should be done daily for at least 30 minutes. However, it is necessary to avoid physical activity, accompanied by an overload of the muscles of the tire, playing sports. It is useful to have regular swimming in the pool. During sleep it is recommended to use a hard mattress and cushions of small sizes. The workplace should be organized in such a way as to avoid stoop. Long wearing corsets or using orthoses for the spine leads to weakening of the back muscles and therefore is not recommended. There is no need for dietary restrictions. It is necessary to strictly adhere to the general measures of the prevention of acute intestinal and urogenital infections, in which there may be an exacerbation. With the development of inflammation of the eyes, urgent consultation of the ophthalmologist is shown.

Approximate terms of incapacity for work

Determine individually.

[14], [15]

Forecast

The course of the disease and the rate of progression is difficult to predict. Rarely observed extreme variants of the course (excessively fast or very slow progression), but in most patients a wavy current is noted, and the activity can subside spontaneously, without therapy. It is established that the greater the degree of violations of the functions of the spine and joints after 10 years from the onset of the pathological process, the harder the subsequent course. The prognosis is worse if ankylosing spondyloarthritis develops in childhood, as well as in the early (and early years of the disease) hip, eye, and aortic lesions, with the appearance of radiological changes and spinal disorders, with a weak effect of NSAIDs.

[16], [17], [18], [19], [20]