Should My Son Continue Taking Pain Relievers for Ankylosing Spondylitis?

I'm not sure whether to continue taking anti-inflammatory pain relievers?

Hello Doctor, my son is currently 19 years old and has been diagnosed with ankylosing spondylitis for over two years.
His only symptom has been pain in the sacroiliac joint in his buttocks.
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 levels.
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 two tablets of Salofalk (500 mg) daily and has not needed to take anti-inflammatory painkillers, resulting in complete relief from buttock pain and controlled inflammation levels.
However, two months ago, although the buttock pain has resolved, he began experiencing mild pain in the lower back (around the level of the navel) that occurs only when he leans back a bit more.
Normal activities, such as playing sports, do not cause any issues, and there is no increased pain upon waking or after daytime activities.
I would like to ask the doctor: 1) Since the previous buttock pain affected his ability to exercise and daily life, he had to take a considerable amount of anti-inflammatory painkillers.
Now that the buttock pain has resolved and only mild lower back pain occurs when leaning back, which does not affect daily life or exercise, can he continue taking two tablets of Salofalk daily and ignore the mild lower back pain? I am concerned that after taking so many anti-inflammatory painkillers for a year and a half, continuing to take them might lead to damage to some organs, which would be worse than the mild lower back pain.

2) Is there a characteristic of ankylosing spondylitis where it initially affects the sacroiliac joint and then gradually invades the spine, and when it starts to affect the spine, it no longer invades the sacroiliac joint? I ask this because I have observed that my son initially had pain in the left buttock, then it shifted to the right buttock, and after experiencing right buttock pain, the left side has not hurt again.
Now that he has mild lower back pain, the right buttock has not hurt either.

Thank you, Doctor.

Yong, 50~59 year old female. Ask Date: 2022/08/04

Dr. Zeng Guosen reply Internal Medicine

1) If ESR/CRP levels are normal and symptoms are stable, pain medication may not be necessary, but regular monitoring of ESR/CRP and X-rays is required.
2) Ankylosing spondylitis typically begins by affecting the sacroiliac joints, and approximately half of the patients will experience spinal involvement, though the reason is unclear.
The condition can fluctuate year by year, often leading to progressive severity in both locations; if one area is unaffected, the other may still be problematic.
Regular X-ray examinations are still necessary.
Thank you for your question.

Reply Date: 2022/08/04

More Info

When managing Ankylosing Spondylitis (AS), particularly in a young patient like your son, it is crucial to balance effective pain management with the potential risks associated with long-term use of anti-inflammatory medications. Here’s a detailed response to your questions:
1. Continuation of Pain Relievers: Given that your son has been on pain relievers, particularly Salazopyrin (sulfasalazine), and has experienced significant improvement in his symptoms, it is reasonable to consider continuing this medication. Since he is currently asymptomatic regarding his buttock pain and only experiences mild discomfort in the lower back when extending backward, it may be appropriate to maintain the current regimen of Salazopyrin without additional anti-inflammatory medications. However, it is essential to have regular follow-ups with his healthcare provider to monitor his condition and any potential side effects from long-term medication use. Chronic use of anti-inflammatory drugs can lead to gastrointestinal issues, liver dysfunction, or renal impairment, so periodic blood tests and assessments are advisable.

2. Nature of Ankylosing Spondylitis: AS is characterized by inflammation that typically starts in the sacroiliac joints (located in the pelvis) and can progress to affect the spine. It is common for patients to experience pain in one side of the pelvis, which may later shift to the other side, as you have observed with your son. This pattern can occur as the disease progresses, but it does not necessarily mean that the inflammation will stop affecting the sacroiliac joints altogether. Instead, the disease can manifest differently over time, and while it may seem that one area improves, another may begin to show symptoms.
The fact that your son’s ASAS score is low (1.6) indicates low disease activity, which is a positive sign. However, it is essential to remain vigilant, as AS can lead to structural changes in the spine over time, even in the absence of significant pain. Regular monitoring and adjustments to his treatment plan are crucial.

In summary, it seems reasonable for your son to continue with Salazopyrin as long as he is monitored for any side effects and maintains regular check-ups with his healthcare provider. The mild discomfort in his lower back should be noted, but if it does not interfere with his daily activities or quality of life, it may not require immediate intervention. However, any changes in symptoms or new concerns should prompt a discussion with his doctor to ensure that his treatment remains optimal and that the disease is managed effectively.
In addition to medication, consider incorporating physical therapy and regular exercise into his routine, as these can help maintain mobility and reduce stiffness associated with AS. Always consult with a rheumatologist or a healthcare provider specializing in AS for personalized advice and treatment adjustments.

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