Managing Medication Changes for Ankylosing Spondylitis: A Patient's Journey

Q: Managing Medication Changes for Ankylosing Spondylitis: A Patient's Journey

Hello, thank you for your question. <br>Here are my responses： <br>1) Since my child started taking 2 Salazopyrin and 1 Methotrexate daily, his CRP has significantly decreased to 0.2 mg/dL, which was previously unattainable even with 2 Sulfasalazine daily (although his ESR occasi

How to switch medications?

Hello Doctor, my son is currently 19 years old and has been diagnosed with ankylosing spondylitis for 2 years.
His only symptom is pain in the sacroiliac joint.
At the onset of the disease, he took one tablet of Voltaren (60 mg) daily for a month, but it had no effect on pain or inflammation markers.
He then switched to taking 1-2 tablets of Celebrex (200 mg) daily, which provided some control, but not completely.
However, it was better than taking only Voltaren or not taking anything at all.

For the past four months, he has been taking 2 tablets of Sulfasalazine (500 mg each) and 1 tablet of Voltaren daily, which has completely alleviated his buttock pain and controlled his inflammation markers.
However, two months ago, although the buttock pain has resolved, he started experiencing lower back pain daily (it only hurts slightly when leaning back more, and he has no issues during normal activities like playing sports; it doesn't hurt more upon waking or improve after daytime activities).

I would like to ask the doctor: 1) Since my son's CRP has significantly decreased to 0.2 mg/dL, which was not achievable even with 2 tablets of Celebrex daily, and his buttock pain has resolved, can I continue giving him 2 tablets of Sulfasalazine daily and switch from 1 tablet of Voltaren to 1 tablet of Celebrex daily? I suspect that the improvement is due to Sulfasalazine rather than Voltaren, and I want to see if switching to Celebrex can help with the mild lower back pain when leaning back.

2) Should I increase the Sulfasalazine dosage to 3 tablets daily (1 in the morning and 2 in the evening) and stop taking Celebrex or Voltaren? I wonder if this would be more beneficial than the first option.

3) Previously, the buttock pain affected his sports and daily life, necessitating medication.
Now that the buttock pain has resolved and he only experiences mild lower back pain when leaning back, which does not affect his daily life or activities, and with the ASAS score around 1.6 (indicating low disease activity), can he just continue taking 2 tablets of Sulfasalazine daily? If anti-inflammatory pain medication does not help with the mild lower back pain, should we just ignore it?
Thank you, Doctor.

Ting, 50~59 year old female. Ask Date: 2022/07/28

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your question.
Here are my responses:
1) Since my child started taking 2 Salazopyrin and 1 Methotrexate daily, his CRP has significantly decreased to 0.2 mg/dL, which was previously unattainable even with 2 Sulfasalazine daily (although his ESR occasionally remains at 39), and he no longer experiences pain in his buttocks.
Therefore, I would like to continue taking 2 Salazopyrin daily and switch from 1 Methotrexate to 1 Sulfasalazine daily.
Is this acceptable? (Because Methotrexate has not been effective in alleviating my child's buttock pain, as mentioned earlier, it was only after taking 2 Salazopyrin and 1 Methotrexate daily for the past 4 months that the pain completely resolved and his indices were controlled.
I suspect this is due to Salazopyrin and not Methotrexate, so I want to try Sulfasalazine to see if it can address the mild lower back pain when leaning back.) --> You can try this, but do not reduce the Salazopyrin dosage.
Salazopyrin is the fundamental medication, and it can be increased if necessary.
2) Alternatively, you could increase the Salazopyrin dosage to 3 tablets daily (1 in the morning and 2 in the evening), but do not take Sulfasalazine or Methotrexate.
I wonder if this would be better than the first option.
--> Whether to increase the Salazopyrin dosage can be discussed with your physician.
If your child’s weight allows, there is generally room for dosage increase.
3) Previously, the buttock pain affected my child's physical activity and daily life, necessitating the use of several medications.
Now that the buttock pain has resolved, he only experiences mild lower back pain when leaning back, which does not affect his daily life or activities, and his ASAS score is around 1.6 (indicating low disease activity).
Can my child continue taking just 2 Salazopyrin daily, and if the mild lower back pain does not respond to anti-inflammatory pain relievers, should we just ignore it? --> Pain relief medication is intended to alleviate pain, improve quality of life, and enhance the patient’s willingness to engage in physical activity, creating a positive cycle that ultimately aims for the goal of not needing pain medication.
If your child is currently pain-free, he can continue taking Salazopyrin without the need for pain relievers.

Best regards from the Allergy, Immunology, and Rheumatology Department of Changhua Hospital, Ministry of Health and Welfare.

Reply Date: 2022/07/28

More Info

Managing medication changes for Ankylosing Spondylitis (AS) can be a complex process, especially when considering the balance between symptom control and potential side effects. Your son’s journey with AS has involved various medications, and it’s great to hear that he has found some relief with the current regimen. Let’s address your questions one by one.

1. Switching from Metotrexate to Sulfasalazine: It seems that your son has had a better response with Sulfasalazine (Salsalate) compared to Methotrexate (Wankesi). Given that his CRP levels have significantly decreased and he is experiencing less pain, it may be reasonable to continue with Sulfasalazine while reducing Methotrexate. However, it’s essential to consult with his rheumatologist before making any changes. The doctor can assess the overall treatment plan, considering the potential benefits and risks of altering the medication regimen. It’s crucial to ensure that the new combination will continue to manage his symptoms effectively without compromising his health.

2. Increasing Sulfasalazine dosage: Increasing the dosage of Sulfasalazine to three pills a day could potentially provide additional relief, especially if the lower back pain persists. However, this should also be discussed with his healthcare provider. The doctor can evaluate whether this increase is appropriate based on his current health status, lab results, and any potential side effects. It’s important to monitor for any adverse reactions, especially when adjusting dosages.

3. Managing mild lower back pain: Since your son’s lower back pain does not significantly impact his daily activities or sports, it may be reasonable to continue with just Sulfasalazine if it keeps his symptoms manageable. However, it’s essential to keep an eye on this pain. If it worsens or begins to affect his quality of life, further evaluation may be necessary. The ASAS (Ankylosing Spondylitis Assessment Score) indicating low disease activity is a positive sign, but ongoing monitoring is crucial.

In addition to medication management, consider incorporating non-pharmacological approaches to help manage symptoms. Physical therapy, regular exercise, and maintaining good posture can be beneficial for individuals with AS. Stretching and strengthening exercises can help improve flexibility and reduce stiffness, which may alleviate some discomfort in the lower back.

Lastly, it’s essential to maintain open communication with your son’s healthcare team. Regular follow-ups will allow for adjustments in treatment as needed and ensure that any new symptoms are addressed promptly. If the lower back pain persists or worsens, further investigation may be warranted to rule out any underlying issues.

In summary, while it seems reasonable to continue with Sulfasalazine and consider adjusting the Methotrexate dosage, it’s crucial to involve his healthcare provider in these decisions. They can provide personalized advice based on his specific situation and ensure that he continues to receive optimal care for his Ankylosing Spondylitis.

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