Should We Change Medications for Ankylosing Spondylitis Management?

Should the medication be changed?

Hello Doctor: My child (born June 2003, currently 18 years and 6 months old) developed ankylosing spondylitis in June 2019 (symptoms only included sacroiliac joint pain, with no morning stiffness).
However, he was only diagnosed with ankylosing spondylitis around November 2020.
In the past year since diagnosis, he has been actively taking medication (specifically, Celebrex 200 mg).
The effects of the medication over the past year are as follows: 1) Before starting the medication, CRP was 1.8 mg/dL and ESR was 38 mm/hr.
2) If he averages 1.5 pills per day (taking 1 pill on Mondays, Wednesdays, and Fridays, and 2 pills on Tuesdays, Thursdays, and Saturdays, or taking 2 pills per day for the first half of the month and 1 pill per day for the second half), the sacroiliac joint pain subsides, but CRP levels remain between 0.3-0.6 mg/dL and ESR between 14-20 mm/hr (only once it suddenly rose to 45).
3) If he averages only 1 pill per day, the sacroiliac joint pain returns, but interestingly, CRP and ESR values are similar to when he takes 1.5 pills.
I would like to ask the doctor: 1) Before taking Celebrex for this past year, he had taken Voltaren (60 mg) for 28 days, 1 pill per day, which not only failed to relieve pain but also caused CRP to rise from 1.2 to 1.6 and ESR from 27 to 46.
Should we consider going back to Voltaren to see if it might work better now? 2) Similar to the previous question, before taking Celebrex, he also took Meloxicam for 20 days (1 pill per day of 15 mg), which also did not relieve pain, but unfortunately, we did not check the indices at that time.
Should we consider trying Meloxicam again to see if it might work better? 3) If we decide not to take Voltaren or Meloxicam and continue with Celebrex at 1.5 pills per day, is that acceptable? Or should we increase to the maximum dosage of 2 pills per day? I am concerned that long-term use of the maximum dosage may not be good for my child’s health.
4) Given the current medication situation (although pain is managed, CRP and ESR levels have not decreased to normal values and are still fluctuating around the upper limits of the standard), if financially feasible, would the doctor recommend considering self-paying for biologic therapy? 5) Is it necessary to continue biologic therapy for a lifetime? Is there a possibility that after 1-2 years, if the disease activity decreases, we could switch to lighter medications for management? 6) Based on my child's condition, what are the chances of being approved for government-funded biologic therapy? 7) Aside from regularly taking anti-inflammatory and pain relief medications, does my child need to take any dietary supplements or follow a specific diet to help manage inflammation in the sacroiliac joint? (Since the indices cannot be lowered significantly, I would like to consider taking some supplements to mitigate inflammatory damage until we find the best approach.) Thank you, Doctor.

Zhengzhong, 50~59 year old female. Ask Date: 2022/01/04

Dr. Zeng Guosen reply Internal Medicine

1.
At that time, the patient was unable to stabilize their condition with the current medication, so it may be worth trying the new medication recently; if it proves ineffective, we can switch back.
2.
It may be worth trying the new medication recently; if it proves ineffective, we can switch back.
3.
Anti-inflammatory and analgesic medications remain the first-line treatment for AS-related back pain.
The treatment goal is to have no or mild symptoms, normal inflammatory markers, and stable spinal X-rays.
In addition to increasing the dosage of pain medications, we may consider trying some immunomodulatory drugs.
4.
If financially feasible, it is possible to try self-funded biologics.
5.
Biologics do not necessarily need to be administered for a lifetime; it depends on the patient's condition.
6.
To apply for coverage for biologics under health insurance, the patient needs to have used either 200 mg of Certolizumab Pegol (Cimzia) twice or 90 mg of Secukinumab (Cosentyx) or 15 mg of Etanercept (Enbrel) for three months, but still have ESR > 28 and CRP > 1 mg/dL.
7.
Currently, there are no dietary supplements proven to slow down the inflammatory destruction of the sacroiliac joints.
Thank you for your question.

Reply Date: 2022/01/04

More Info

When managing Ankylosing Spondylitis (AS), it is crucial to evaluate the effectiveness of current medications and consider potential changes based on the patient's response to treatment. Your son has been on Celecoxib (known as "希樂葆") for a year, and while he has experienced pain relief, his inflammatory markers (CRP and ESR) have not normalized. Here’s a detailed response to your questions:
1. Considering a Return to Meloxicam (萬客適): Since your son previously tried Meloxicam without achieving pain relief and saw an increase in inflammatory markers, it may not be beneficial to return to this medication. Each patient responds differently to NSAIDs, but given the prior experience, it might be more prudent to explore other options rather than reverting to a medication that has not worked in the past.

2. Revisiting Mefenamic Acid (美息炎): Similar to Meloxicam, if Mefenamic Acid did not provide pain relief previously, it may not be effective now. However, if there are no other viable options and you wish to explore all avenues, a trial could be considered, but it should be done under close supervision and with a clear plan for monitoring.

3. Continuing with Celecoxib: If Celecoxib at 1.5 capsules per day is managing pain effectively, it is reasonable to continue at this dosage. However, if you are concerned about long-term use at maximum dosage, it is essential to discuss this with your physician. They can help weigh the risks and benefits and may suggest periodic evaluations to monitor for any potential side effects.

4. Biologic Therapy Consideration: Given that your son’s inflammatory markers remain elevated despite pain control, discussing the option of biologic therapy with your healthcare provider is advisable. Biologics can be very effective in managing AS and may help normalize inflammatory markers. If financially feasible, this could be a worthwhile investment in his health.

5. Duration of Biologic Treatment: Biologics are often used long-term, but there is potential for tapering off after a period of effective treatment. Some patients may find that their disease activity decreases, allowing for a transition to less aggressive therapies. This should be a decision made collaboratively with your healthcare provider based on ongoing assessments of disease activity.

6. Insurance Approval for Biologics: The likelihood of approval for biologic therapy through insurance can vary based on the specific criteria set by the insurance provider and the severity of the disease. It is advisable to work closely with your healthcare provider to document the need for such treatment, which can improve the chances of approval.

7. Dietary and Supplement Considerations: While there is no specific diet that cures AS, certain anti-inflammatory foods may help manage symptoms. A diet rich in omega-3 fatty acids (found in fish, flaxseeds, and walnuts), fruits, vegetables, and whole grains can be beneficial. Additionally, some patients find relief with supplements like curcumin or omega-3 fish oil, but these should be discussed with a healthcare provider to ensure they do not interfere with prescribed medications.

In conclusion, managing Ankylosing Spondylitis is a multifaceted approach that includes medication, lifestyle modifications, and possibly biologic therapy. Regular follow-ups with your healthcare provider are essential to adjust treatment plans based on your son’s evolving needs. Always consult with a physician before making any changes to medication or treatment strategies.

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