Medication vs. Biologics: Which is Better for Ankylosing Spondylitis?

Is it better to take medication or to receive a biologic treatment?

Hello Doctor, my son is 20 years old and has been diagnosed with ankylosing spondylitis for 3.5 years.
It took 1.5 years after the onset of symptoms to confirm the diagnosis and begin formal treatment.
The overview of his treatment over the past two years is as follows: In the first year, he took medications like Voltaren and Meloxicam, which were ineffective.
Later, he started taking Celebrex, which showed some improvement, averaging about one pill per day (sometimes taking two pills, sometimes just one, and occasionally not taking any when he was not in pain).
His CRP levels decreased from an initial 1.7 to a controlled range of 0.4-0.9, while his ESR fluctuated between 15-45 (initially at 36).
He experienced some improvement in pain (in the hips and lower back).
In the second year, he took two pills of Sulfasalazine and two pills of Celebrex daily, with CRP levels controlled between 0.2-0.4 and ESR between 15-25, and he is almost pain-free.
A year ago, an X-ray showed that his hips were approximately at grade 1, and there was no inflammation in the spine.
I would like to ask the doctor: 1) Although taking two pills of Sulfasalazine and two pills of Celebrex daily helps control his condition, I am concerned about the potential long-term side effects (such as cardiovascular issues or kidney disease) from taking so many medications.
Would switching to a biologic agent have fewer significant side effects? (Is it worth the out-of-pocket expense to switch to a biologic agent?) 2) Between "continuing with two pills of Sulfasalazine and two pills of Celebrex" and "switching to a biologic agent at my own expense," could you provide some recommendations? Thank you, Doctor.

Hao, 50~59 year old female. Ask Date: 2023/02/07

Dr. Zeng Guosen reply Internal Medicine

The general principle is that traditional oral medications are the first-line treatment.
If the condition is stable, the use of biologics is not recommended.
It may be worth considering a reduction in medication and monitoring the situation.
Biologics are also a type of medication and can have associated side effects.
You should discuss this with your attending physician.
Thank you.

Reply Date: 2023/02/07

More Info

When considering the treatment options for Ankylosing Spondylitis (AS), it is essential to weigh the benefits and risks of traditional medications versus biologics. Your son’s experience with various medications, including NSAIDs like Meloxicam (萬客適) and Sulfasalazine (希樂葆), indicates that he has been under treatment for a significant period. His CRP and ESR levels suggest that inflammation is being managed effectively, and the reduction in pain is a positive sign.

1. Long-term Use of Traditional Medications: You expressed concern about the long-term use of Sulfasalazine and NSAIDs, particularly regarding potential side effects such as cardiovascular issues and kidney damage. It is true that prolonged use of NSAIDs can lead to gastrointestinal complications, renal impairment, and cardiovascular risks, especially in individuals with pre-existing conditions. Sulfasalazine, while generally well-tolerated, can also have side effects, including liver toxicity and hematological issues. Regular monitoring through blood tests is crucial to detect any adverse effects early.

2. Biologics as an Alternative: Biologics, such as TNF inhibitors (e.g., Etanercept, Infliximab) and IL-17 inhibitors (e.g., Secukinumab), have transformed the management of AS. They target specific pathways in the inflammatory process, often leading to rapid and significant improvement in symptoms and quality of life. The side effects of biologics can include increased risk of infections and potential malignancies, but they are generally considered to have a more favorable long-term safety profile compared to chronic NSAID use.
The decision to switch to biologics should consider several factors:
- Efficacy: If your son is experiencing good control of his symptoms with current medications, the immediate need to switch may not be pressing. However, if he is concerned about long-term effects, discussing biologics with his rheumatologist could be beneficial.

- Cost: Biologics can be expensive and may not be covered by insurance, depending on your location and insurance plan. Evaluating the financial implications is essential.

- Monitoring: Transitioning to biologics would require regular follow-ups and monitoring for side effects, including routine blood tests and screenings for infections.

3. Recommendations: Given the current management of your son’s AS, it may be prudent to continue with the existing regimen while maintaining regular follow-ups with his healthcare provider. If he experiences a flare-up or if his current treatment becomes less effective, discussing the option of biologics would be advisable.
In conclusion, both traditional medications and biologics have their place in managing Ankylosing Spondylitis. The choice between them should be individualized, taking into account the severity of the disease, response to current treatments, potential side effects, and personal preferences regarding treatment goals. Consulting with a rheumatologist who specializes in AS can provide further insights and help navigate this decision effectively.

Similar Q&A

Understanding Biologics for Ankylosing Spondylitis: Key Questions Answered

Hello, doctor. My son is 18.7 years old and is a patient with ankylosing spondylitis. I would like to ask some questions regarding biologic agents: To save the doctor's time, I would like to define the following conditions as "Condition A" (the prescription of anti...

Dr. Gao Jiankai reply Internal Medicine
Hello, thank you for your questions. There are many inquiries, so I can only provide brief responses as follows: 1) If you apply for public funding to receive biologic therapy and it is approved, after a period of treatment, if the inflammatory markers normalize and there is no...

Assessing Long-Term Risks of Biologics vs. Traditional Treatments

Dear Dr. Gao, Below the asterisks is the question I raised on January 17. I appreciate your detailed response, and I would like to ask a few more questions: 1) I want to focus on the long-term severe (or life-threatening) side effects. The long-term severe (or life-threatening)...

Dr. Gao Jiankai reply Internal Medicine
Hello, thank you for your inquiry. Here is my consolidated response: 1) I would like to focus on the long-term severe (or fatal) side effects. The long-term severe (or fatal) side effects of Celebrex (celecoxib) include cardiovascular, renal, and gastrointestinal issues. The lon...

Understanding Biologics for Ankylosing Spondylitis: Weight Gain and Edema Concerns

Hello, Doctor: I have ankylosing spondylitis, and since the medication treatment has not been very effective, my physician evaluated my condition and started me on biologic therapy. It has been four months since the treatment began, and I have recently noticed some swelling and a...

Dr. Gao Jiankai reply Internal Medicine
Hello, thank you for your message. Currently, there is no clear evidence indicating that the administration of biologic agents causes edema or weight gain as side effects; in fact, the likelihood of side effects is higher with other medications, particularly anti-inflammatory pai...

Understanding Immunomodulators for Ankylosing Spondylitis Patients

Hello Doctor: I am a patient with ankylosing spondylitis. I have undergone an MRI, which showed no inflammation at L4/5 and L5/S1, but there is inflammation in the sacroiliac joint. I have some questions for you. First: Is the sacroiliac joint considered a spinal joint or a perip...

Dr. Zeng Guosen reply Internal Medicine
User 1: The sacroiliac joint and the spinal joints are classified as axial joints, not peripheral joints. User 2: Only in the case of inflammation of the sacroiliac joint, it is generally recommended to take non-steroidal anti-inflammatory drugs (NSAIDs), and there are also biolo...