Biologic Therapy in Ankylosing Spondylitis: Benefits, Risks, and When Is It Really Needed?

 

Biologic Therapy in Ankylosing Spondylitis: Benefits, Risks, and the Importance of Expert Care

Biologics Are Powerful Medicines—But They Are Not the First Treatment for Everyone

Ankylosing spondylitis (AS), now classified under axial spondyloarthritis (axSpA), is a chronic inflammatory disease that primarily affects the spine and sacroiliac joints. If left untreated, it can lead to chronic pain, stiffness, reduced mobility, spinal fusion, and impaired quality of life.

The introduction of biologic disease-modifying antirheumatic drugs (bDMARDs) has transformed the treatment of AS. Many patients experience remarkable improvements in pain, stiffness, function, and quality of life. However, biologics are not a cure, not suitable for every patient, and not the first treatment option in most cases.

These medications should always be prescribed and monitored by specialists experienced in managing inflammatory arthritis, such as rheumatologists, in collaboration with rehabilitation physicians and other healthcare professionals when appropriate.

Understanding Ankylosing Spondylitis

Unlike osteoarthritis, which is primarily a degenerative condition, ankylosing spondylitis is an immune-mediated inflammatory disease.

Common symptoms include:

• Persistent back pain lasting more than three months

• Morning stiffness lasting over 30 minutes

• Pain that improves with exercise but not with rest

• Night pain

• Reduced spinal mobility

• Fatigue

• Heel pain (enthesitis)

• Peripheral arthritis

• Eye inflammation (uveitis)

Early diagnosis is crucial to prevent long-term disability.

What Are Biologic Medicines?

Biologic therapies are targeted medications that block specific components of the immune system responsible for inflammation.

Unlike conventional painkillers, biologics aim to control the disease process rather than simply reduce pain.

Common biologic targets include:

Tumor Necrosis Factor (TNF) inhibitors

Examples include:

• Adalimumab

• Etanercept

• Infliximab

• Golimumab

• Certolizumab pegol

Interleukin-17 (IL-17) inhibitors

Examples include:

• Secukinumab

• Ixekizumab

These drugs have significantly improved outcomes for many patients with active ankylosing spondylitis.

Are Biologics the First Treatment?

No.

Current international recommendations generally advise a stepwise approach.

Initial management usually includes:

• Patient education

• Regular exercise

• Clinician monitored rehabilitation

• Smoking cessation

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Management of posture and spinal mobility

Biologics are typically considered when:

• Disease activity remains high despite adequate NSAID therapy.

• Symptoms significantly affect daily life.

• There is objective evidence of ongoing inflammation.

• The diagnosis has been confirmed by a specialist.

Thus, biologics are neither the first option for every patient nor the "last resort." They are an appropriate treatment for selected patients when indicated.

Who May Benefit from Biologics?

Patients with:

• Persistent inflammatory back pain

• Active disease despite standard therapy

• Elevated inflammatory markers (when present)

• MRI evidence of active inflammation

• Recurrent uveitis or other disease manifestations in selected situations

• Significant impairment in function and quality of life

Patient selection is critical.

Benefits of Biologic Therapy

For appropriately selected patients, biologics can:

Reduce inflammation

They target key inflammatory pathways responsible for disease activity.

Relieve pain and stiffness

Many patients report substantial improvements within weeks to months.

Improve mobility

Better spinal movement can enhance daily functioning.

Improve quality of life

Reduced pain often leads to better sleep, work productivity, and participation in daily activities.

Reduce disease activity

Effective treatment can help control ongoing inflammation and may reduce progression of structural damage, although complete prevention is not guaranteed.

Potential Risks

Like all potent therapies, biologics have important risks.

These include:

Increased susceptibility to infections

Examples:

• Tuberculosis (TB)

• Hepatitis B reactivation

• Serious bacterial infections

• Opportunistic infections

This is why screening before treatment is essential.

Injection or infusion reactions

Some patients develop:

• Pain

• Swelling

• Rash

• Fever

Most reactions are manageable.

Rare neurological complications

Although uncommon, biologics may not be suitable for patients with certain demyelinating neurological disorders.

Heart failure considerations

Certain biologics require caution in patients with moderate to severe heart failure.

Malignancy

Current evidence does not show a major increase in overall cancer risk for most patients, but long-term monitoring remains important.

Pregnancy

Some biologics may be continued in selected situations, while others require modification. Decisions should always involve the treating specialist.

Why Screening Before Biologics Is Essential

Before starting treatment, specialists usually evaluate for:

• Tuberculosis

• Hepatitis B

• Hepatitis C

• HIV (when appropriate)

• Complete blood count

• Liver function

• Kidney function

• Vaccination status

Ignoring these steps can expose patients to serious complications.

Why Self-Prescribing or Inappropriate Use Is Dangerous

Because biologics can dramatically improve symptoms, there is a misconception that they are suitable for anyone with back pain or arthritis.

This is incorrect.

Biologics should never be started solely because:

• Someone read about them online.

• A friend improved with them.

• A non-specialist recommended them without confirming the diagnosis.

These medicines require:

• Accurate diagnosis

• Appropriate patient selection

• Baseline investigations

• Ongoing monitoring

• Management of side effects

Inappropriate use can expose patients to unnecessary risks without providing benefit.

The Role of the Rehabilitation Physician

Even when biologics are prescribed, medication alone is not enough.

A Rehabilitation Physician focuses on maintaining and improving function through:

• Individualized exercise programs

• Posture correction

• Spinal mobility exercises

• Chest expansion exercises

• Strengthening and flexibility training

• Gait and balance assessment

• Pain management strategies

• Functional rehabilitation

• Ergonomic advice

• Lifestyle modification

Rehabilitation complements medical treatment and helps patients remain active and independent.

Common Myths

Myth: Biologics cure ankylosing spondylitis.

Fact: They control inflammation but do not cure the disease.

Myth: Every patient with ankylosing spondylitis needs biologics.

Fact: Many patients respond well to NSAIDs, exercise, and rehabilitation.

Myth: Pain relief means the disease has disappeared.

Fact: Disease monitoring remains important even when symptoms improve.

Myth: Once started, biologics never need reassessment.

Fact: Treatment should be reviewed regularly to ensure ongoing benefit and safety.

Key Take-Home Messages

• Biologics have revolutionized the treatment of ankylosing spondylitis.

• They are not the first treatment for every patient.

• They should be prescribed only after careful evaluation and confirmation of diagnosis.

• Screening for infections and other risks is mandatory before starting therapy.

• Regular monitoring is essential throughout treatment.

• Rehabilitation, exercise, posture training, and patient education remain fundamental components of care.

Conclusion

Biologic therapies represent one of the greatest advances in the management of ankylosing spondylitis. For the right patient, they can provide substantial relief from pain and stiffness, improve function, and enhance quality of life. However, these medications are powerful immunomodulatory agents that require careful patient selection, thorough pre-treatment screening, and close follow-up.

Patients should avoid viewing biologics as either a universal first-line therapy or a treatment to be started without specialist input. The best outcomes are achieved through a multidisciplinary approach that combines expert rheumatology care, rehabilitation medicine, regular exercise, and long-term monitoring.

Biologics should always be prescribed and supervised by clinicians with expertise in inflammatory arthritis—not solely on the basis of information read online or isolated anecdotal experience. Evidence-based medicine, careful assessment, and ongoing monitoring are essential for safe and effective treatment.

About the Author

Dr. Abhinav Singh, MBBS, MD (PMR)
Pain & Rehabilitation Physician
Director, Jeejeevisha Pain Clinic (JPC)
Kendriya Vidhyalaya Road, Kankarbagh, Patna
📞 9003843916