Ankylosing Spondylitis is a chronic inflammatory condition that affects one out of hundred citizens of the western world. It’s characterized by inflammation and fusion of the spine starting with the sacroiliac joints and finishing in the cervical vertebras. Other big joints such as hips, shoulders, elbows and knees are usually affected. The HLA-b27 gene is no longer important for the diagnosis because of the increase in the number of sufferers that don’t have it and still experience the symptoms of the same disease. AS can manifest itself as inflammation of the uvea (uveitis) and it’s strongly related to Crohn disease. Current treatment depends of the disease activity, varying between NSAIDS, DMARDS and biologic treatment, this last one being a huge step forward in the treatment, slowing the progress of the disease and improving notoriously patient’s quality of life. Still, almost 40% of the patients don’t react to antiTNF therapy and can’t reach remission. Those that are able to achieve this, have to cope with serious side effects that come with these drugs. Some of the most feared adverse reactions to biologic drugs are the increased risk of cancer and development of another autoimmune diseases (there are case reports of patients developing multiple sclerosis, lupus and psoriasis after the first injections). Therefore, even knowing that the quality of life of the average AS patient is better nowadays than it was 20 years ago, we shouldn’t be satisfied because patients depend on the dispensation of expensive drugs, chronic pharmacologic therapy, life threatening side effects and, even worse, a lot of them are still suffering day after day.
Sacroilitis, hallmark of AS. Source: EMedicine
AS is the disease that raises the most interest in the bowel-joints connection. Between 5 and 10% of the patients with AS develop IBD. Moreover, almost 60% of them have subclinical intestinal lesions that can be seen on a colonoscopy. An increased intestinal permeability has been reported in AS and several easily treatable intestinal infections such as giardiasis can develop a reactive arthritis that mimics AS. One of the most used drugs in AS is Sulfasalazine, an intestinal antiinflammatory used also in the treatment of IBD. Even today, researchers still don’t know why Sulfasalazine reduces joint disease. The only fact is that it reduces intestinal permeability and has small antibacterial effect, attributed to Sulfapyridine.
Evolution of AS. Source: Arthritis world association
Due to this clear relationship with the bowel, some doctors have tried to modify the diet of their AS patients in order to alter the progress of the disease. Seignalet treated 122 AS patients with his ancestral diet, with a 90% success rate. Lutz had a similar success with a ketogenic diet (less than 72g of carbohydrates per day). Nowadays, many patients are successful with a paleo diet. There’s something in common in all these diets: drastic reduction of carbohydrates through elimination of grains and processed food. Here’s where we must talk about the most famous dietetic treatment of this disease: the Low Starch diet, developed by Alan Ebringer and followed mostly in the anglo saxon culture. In this diet patients had to remove or reduce the ingestion of rice, potatoes or bread and increase the consumption of fish, meat and vegetables.
Some patients went totally no starch and had even better results. Ebringer tried to explain his theory by pointing to one specific bacteria as the culprit of the disease process: Klebsiella pneumoniae. Kp is usually present in the human bowel and, in Ebringer’s opinion, would cross the intestinal epithelium and, due to the fact that its genome is similar to the HLA-B27 gene, would cause a immune reponse through its interaction with the mentioned gene. This theory is called molecular mimicry.
Molecular mimicry between HLA B27 gene and nitrase reductase peptide of Kp. Source: Symbiosis
The only proofs that Ebringer showed to confirm his theory were:
1) A poorly designed study that tried to show a relationship between Klebsiella’s antibodies in faeces and AS disease activity. The studies trying to reproduce this result failed one after another.
2) The fact that Kp uses starch as its nutrient. The consumption of starchy foods such as rice or potatoes would therefore increase Kp in the bowel and disease activity. Every researcher specialized in this knows that not only Kp, but the vast majority of bacterial strains in the human bowel need starch (soluble fiber) as food. Eliminating starch from your diet will modify your ENTIRE gut flora, not just Kp.
Both proofs were discredited and aren’t taken into account when studying the relationship between gut flora and AS disease activity. Molecular mimicry falls by its own weight: HLA b27 patients still develop AS. Patients without Kp antibodies still develop AS. Ebringer hasn’t got an answer for any of these cases.
Kp is definitely not the only culprit of the inflammatory process in AS. There are probably several bacterias that interfere in the process, which is still unknown and most probably multifactorial. Bacterial and food proteins cross the intestinal barrier starting an immune reponse. Ebringer’s hypothesis wasn’t correct but that doesn’t mean that his treatment isn’t useful. The no starch diet is nowadays the best non-drug treatment for AS. Despite this, many patients don’t improve enough by simply eliminating starch from their diet so more measures are needed.
AS treatment should be directed to restoring the intestinal barrier, modifying the microbiota and management of symptoms.
Our treatment for AS:
- Restore the intestinal barrier:
- Boswellia gum resin or low dose Sulfasalazine
- Intermitent fasting
- Clostridium Butyricum+prebiotic (psyllium seed)
- Modify the microbiota:
- LCHF diet eliminating starches. Max 100g carbohydrates per day.
- Consumption of probiotic foods such as kefir and sauerkraut
- Fecal transplant when the disease is in remission
This book will be useful
- Management of symptoms:
- Curcumin and Boswellia gum resin
- Omega 3 (fish+supplements)
- NSAIDS alleviate symptoms short term but aren’t recommended for chronic treatment
- Physical Therapy in warm swimming pool
A food allergy IGG test could be added in order to adjust better the diet. The effects of a dietetic change are usually noted after 4-12 weeks. In future articles we’ll talk deeply about the LCHF diet. It should be noted that AS is a disease that responds well to dietary measures, therefore we recommend the patients to be well informed about their treatment options.