Evaluating Biologics for Ankylosing Spondylitis: A Patient's Dilemma

Q: Evaluating Biologics for Ankylosing Spondylitis: A Patient's Dilemma

Hello, thank you for your question. <br>Here are my responses： <br>1) Although taking two Salazopyrin and two CellCept daily can effectively manage my child's condition, I am concerned about the potential long-term side effects (such as cardiovascular issues or kidney disease) fr

Should the use of biologic agents be evaluated?

Hello, Doctor Gao.
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 tried medications such as 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 in a day, sometimes just one, and occasionally not taking any when he was pain-free).
His CRP levels decreased from an initial 1.7 to a range of 0.4-0.9, while his ESR fluctuated between 15-45 (initially at 36).
His pain (in the hips and lower back) has improved.
In the second year, he has been taking two pills of Sulfasalazine and two pills of Celebrex daily, with CRP levels controlled between 0.2-0.4 and ESR levels between 15-25, and he is almost pain-free.
A year ago (before starting the two pills of Sulfasalazine and Celebrex), an X-ray showed that his hips were approximately 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 biologics be associated with fewer significant side effects? (Is it worth the out-of-pocket expense to switch to biologics?) 2) Between "continuing with two pills of Sulfasalazine and two pills of Celebrex" and "switching to biologics at my own expense," could you provide some recommendations? Thank you, Doctor.

Shao, 50~59 year old female. Ask Date: 2023/02/08

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your question.
Here are my responses:
1) Although taking two Salazopyrin and two CellCept daily can effectively manage my child's condition, I am concerned about the potential long-term side effects (such as cardiovascular issues or kidney disease) from having to take so many medications.
Therefore, I would like to ask the doctor if switching to biologics would have fewer significant side effects? (Is it worth the out-of-pocket expense to switch to biologics?) --> Biologics also come with their own risks and side effects.
These medications have a stronger immunosuppressive effect, which increases the risk of infections.
Additionally, biologics do not cure the disease and require ongoing treatment for an extended period, which can also be a significant financial burden.
Therefore, it is advisable to consider biologics only when the condition is difficult to control.
2) Between "continuing with two Salazopyrin and two CellCept" and "switching to biologics at my own expense," can the doctor provide some advice? --> Traditional medications generally have lower side effects.
If there are no significant discomforts from the current medications, I would prefer to continue with traditional medications combined with regular exercise.

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

Reply Date: 2023/02/08

More Info

Ankylosing Spondylitis (AS) is a chronic inflammatory disease primarily affecting the spine and sacroiliac joints, leading to pain and stiffness. Your concerns regarding the long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) such as Salazopyrin (撒樂) and Celebrex (希樂葆) are valid, especially considering the potential side effects associated with prolonged use of these medications.

1. Long-term Use of NSAIDs vs. Biologics:
While NSAIDs are effective in managing pain and inflammation in AS, they can have side effects, particularly with long-term use. These may include gastrointestinal issues (like ulcers), cardiovascular risks, and potential kidney damage. Biologics, on the other hand, are designed to target specific pathways in the inflammatory process. They have been shown to be effective in treating AS and may have a different side effect profile. Common biologics for AS include TNF inhibitors (like Etanercept, Infliximab, and Adalimumab) and IL-17 inhibitors (like Secukinumab).
The side effects of biologics can include an increased risk of infections due to their immunosuppressive nature, but they generally do not carry the same gastrointestinal risks as NSAIDs. The decision to switch to biologics should be based on a thorough discussion with your healthcare provider, weighing the benefits against the risks.
2. Decision-Making Between Continuing NSAIDs and Switching to Biologics:
If your son is experiencing good control of his symptoms with the current regimen of Salazopyrin and Celebrex, it may be reasonable to continue this treatment while monitoring for any side effects. However, if there are concerns about long-term use or if the disease progresses, discussing the option of biologics is prudent.
Factors to consider in this decision include:
- Disease Activity: If your son’s disease is well-controlled and he is not experiencing significant symptoms, continuing the current treatment may be appropriate. However, if there are flare-ups or worsening symptoms, biologics may provide better control.

- Side Effects: If your son experiences side effects from NSAIDs, this may prompt a switch to biologics.

- Lifestyle and Quality of Life: If the current treatment allows your son to maintain a good quality of life, it may be worth continuing. However, if he is limited in activities due to pain or stiffness, exploring biologics could be beneficial.

- Cost and Accessibility: Biologics can be expensive and may not be covered by insurance, so financial considerations are also important.

In conclusion, while both treatment options have their pros and cons, the choice should be individualized based on your son’s specific situation, preferences, and the advice of his healthcare team. Regular follow-ups and monitoring of disease activity and medication side effects are essential in managing Ankylosing Spondylitis effectively. It may also be beneficial to consult a rheumatologist who specializes in AS for a more tailored approach to treatment.

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