My Top 5 Ankylosing Spondylitis Treatment Recommendations (They're not what you think)

As you've probably guessed by now, I have ankylosing spondylitis. 

And I remember the day I found out all too well.

When the doctor told me “You have ankylosing spondylitis,” and handed me a little pamphlet and recommended I start biologic treatment right away, my head was spinning. 

I had never heard of the disease before and didn’t know what the hell to do, but one thing was certain: I wasn’t starting treatment of any kind until I understood the risks and what my options were.

My hope is that this free guide to the Top 5 Ankylosing Spondylitis Treatment Options will help you to understand what your BEST options to heal and recover from your ankylosing spondylitis are — far more easily and quickly than I did.

Before we begin, one REALLY important note: as one of my favorite people, Tim Ferriss, likes to say, I’m not a doctor, and I don’t play one on the internet.  Please don’t treat this as medical advice of any kind, and please consult with your doctor before making ANY health related decisions.

Now, let's talk about what will make you feel better!

1. My number one ankylosing spondylitis treatment: change your diet

If you haven’t been living under a rock, at this point you’ve probably heard of gluten free diets, vegan diets, the paleo diet, SCD diets, and on and on — and you might just think they’re a craze by fools who are just doing “what’s cool.”  

However, over the last 20 years or so, there has been a tremendous amount of scientific research in the area of diet, and in particular, the significant role that it appears to play in either causing or at least exacerbating autoimmune disease. 

This is especially true for people with ankylosing spondylitis.

In fact, a groundbreaking study from the UK in the year 1996 showed that a specific set of simple changes to diet “resolved” their ankylosing spondylitis, or improved the signs and symptoms to the degree that many were able to eliminate or significantly reduce their need for medicine; very few drugs can claim the same degree of improvement without significant risks or side effects.


But why is diet so important in Ankylosing Spondylitis?

What the science shows is that individuals with ankylosing spondylitis, or autoimmune disease in general, tend to have high levels of inflammation in their gastrointestinal system, causing it to be more porous and allow more food particulates, bacteria, and so on into their system, which produces an immune reaction.  

Often, the immune cells then  “cross-reacts” to the body’s own tissues which “look” similar to the immune system as the foreign particles, and thus, an autoimmune disease can develop. 

Depending on your genetic makeup, you might get ankylosing spondylitis, multiple sclerosis, Hashimoto’s thyroid, celiac disease, etc. 

You’ve probably heard of heard of celiac disease; this is the most extreme form of this type of reaction to something called gluten, which is part of wheat and other grains.

(By the way, if you want to read an interview with the researcher who actually discovered this connection and exactly how it all works, head here — it’s fascinating!)

All that said, you can control this immune response and reduce the “leakiness” of your gut by eating in such a way that the immune responses are reduced, reducing your inflammation, and in a way that promotes healing of your gut (which will reduce your ankylosing spondylitis severity).


Great, so diet will help you manage your ankylosing spondylitis — but what, specifically, should you eat?


That’s beyond the scope of this post (which is already way too long), but if you want an easy guide to dramatically reduce or even eliminate your ankylosing spondylitis symptoms with diet — and to find out exactly what you should and shouldn’t be eating — I’d recommend my book Living A.S. Free

It’s everything you need to know in around 60 easy to digest pages, plus a companion cookbook and exercise videos. 

The diet I outline is tailored to the specific requirements of someone with ankylosing spondylitis, and it’s backed by scientific research on what works.

However, if you want to really get into the hardcore science of it all and go even deeper, there’s a very comprehensive book by Dr. Sarah Ballantyne called The Paleo Approach that REALLY gets into the deep details, but it’s not specific to ankylosing spondylitis, and really only talks about autoimmune disease generally. 

I think her book is best for science minded folks and for people that have tried my book’s approach and made progress, but not as much as they hoped.

Whichever approach you take, in my view, this is the BEST “treatment” for your ankylosing spondylitis because it is essentially side effect and risk free, and can profoundly influence how you feel!

2. Number two ankylosing spondylitis treatment recommendation: STOP Taking Medicines that Damage Your Gut (they make your ankylosing spondylitis WORSE!)

If you’re paying attention, you’ll remember that I said earlier that your autoimmune disease is mediated by your gut — a leaky gut in particular. 

Thus, making sure it’s healthy and NOT leaky is essential to your well-being if you have ankylosing spondylitis.

However, what you may not be aware of is that the most commonly prescribed medicines for ankylosing spondylitis significantly INCREASE the permeability (leakiness) of your gut, actually making the root cause of your disease WORSE even though they help the symptoms in the short term.

This absolutely blew my mind when I found out, too.  


So, which medicines could you be taking that increase gut permeability?

1. NSAIDs (aspirin, naproxen, etc. — also know as Ibuprofen, Advil, Aleve, etc.)

This is by FAR the most commonly prescribed medicine for sufferers of ankylosing spondylitis, and it is, in my opinion, the absolute worst thing you can take.  

Why?  Because this class of drugs reduces the production of prostaglandins which, when inhibited over time, weakens your gut lining, increasing permeability and exacerbates the immune response which is at the center of your ankylosing spondylitis symptoms.

Don’t believe me?  A study from Oxford University showed that daily aspirin may be behind as many as 3,000 deaths per year due to gastro-intestinal bleeding.

If daily, low dose aspirin can weaken the gut so much as to cause death by gastrointestinal bleeding, imagine what the massive doses required to ward off inflammation from your ankylosing spondylitis could be doing.

However, there’s one important exception to this class of drugs, which is celecoxib, an atypical NSAID which is more targeted, causing far less damage to your gut than traditional NSAIDs. 

If you must take an NSAID, this is the one you want.  It still has this effect, but to a much lower extent.  Still, I would recommend it ONLY for short periods of use, not long term usage.

2. Corticosteroids (like Prednisone)

Because these medicines reduce immune function by raising cortisol (which is how they make you feel better), and cortisol breaks down the gut lining in high doses, they cause exactly the same problem as NSAIDs. 

They may make you feel better short term, but long term they’re only making things worse.  These shouldn't be used, in my opinion, except for in the case of acute trauma, not longer term disease management.

3. Chemotherapy DMARDs like Methotrexate

Methotrexate (and other chemotherapy drugs) are often prescribed for patients with autoimmune disease because they slow the rapid multiplication of cells throughout the body (which is how they exert their anti-cancer effects since cancer multiplies very rapidly).

The reason they are effective for autoimmune disease is that they also slow the production of white blood cells which mount the immune response that is at the center of the pain and inflammation in your autoimmune disease.  

However, there’s a cost. 

There is another type of cell in the body that has some of the fastest turnover of any tissue.  You guessed it: your gastrointestinal system, aka your gut. 

In fact, your entire stomach lining replaces itself every 4 days. 

If these cells can’t reproduce themselves faster than old ones die, then your gut begins to get thinner and weaker over time, exacerbating leaky gut syndrome -- making the root cause of the disease worse in the long term while only masking symptoms in the short term.

4. Alcoholic beverages

“That’s not a medicine!” you say. 

No, it’s not, but it has a huge impact on gut health and a little bit can really wreak havoc on the health of your gut lining. 

If you are a regular drinker and you simply MUST have something to help you relax, then if it's legal in your area and you are comfortable with it, I suggest you consider smoking marijuana instead.  Seriously.  The CBD in marijuana has potent anti-inflammatory effects, and it won't wreak havoc on your gut.  

Otherwise, If you can simply significantly reduce alcohol intake, you’ll feel a LOT better.  Especially alcohol made from wheat (beer) as it's more likely to be triggering an immune response in your gut on top of the damage alcohol itself can cause.

The main thing you need to know / understand:

Virtually NONE of the "traditional" treatments (except celecoxib that I mentioned above and a couple that I'll talk about later in this email series) will actually help your symptoms without exacerbating the ROOT cause of your autoimmune disease, your gut health. 

If you want to get better, you need a different strategy.

3. My number three "treatment:" Daily High Dose Omega-3 Supplements

By this point you’ve surely heard of Omega-3 fatty acids, and probably some of the health benefits. 

Not only is this stuff good for brain health and heart health, but it’s extraordinary at reducing inflammation, especially in rheumatic conditions. 

Here’s a brief excerpt from the Arthritis Foundation:

"According to the results of at least 13 studies involving more than 500 participants, people with rheumatoid arthritis [a very similar disease to ankylosing spondylitis] who took omega-3s supplements had a reduction in joint pain – but not in joint damage.

Other studies suggest that omega-3s may help RA patients lower their dose of non-steroidal anti-inflammatory drugs (NSAIDs). And according to information from NIH, administering fish oil by IV reduces swollen and tender joints in people with RA."

While this study wasn't directly about ankylosing spondylitis, many of the same inflammatory cytokines are involved in both diseases, so what is effective for one is very likely to be effective for the other.

However, be careful, as not all Omega 3 is created equal.  To get the full effects of Omega 3, you need the right mix of EPA and DHA, it needs to come from a clean source (low mercury content cold water fish or krill) and it needs to be properly handled to ensure that it doesn’t go rancid before you consume it.  

In other words, you need to make sure you buy the right brand of Omega 3.

The two brands I’ve had the most success with that I would recommend for anyone with ankylosing spondylitis are Nutrigold Triple Strength Fish Oil Omega-3 Gold and Nordic Naturals Ultimate Omega.  Both of these brands get extremely high marks for quality and safety from third party supplement analysis groups.

As far as dosage, you’ll want to take enough so that you are getting between 2 and 5 grams per day of total Omega 3.  You can see exactly how much there is right on the label.  I aim for 4 grams per day.  More than that and you are likely to increase the risk for negative, unintended side effects.

While that can be fairly expensive, I find that it’s worth every penny as I really notice lower overall inflammation levels from physical activity, and when I used to have chronic inflammation from my ankylosing spondylitis, it really helped.

One thing to note, however, is that it can cause some thinning of the blood (like aspirin) so if you have conditions where this may be a concern, be sure to talk to your doctor before taking Omega-3, especially in the higher dosage range.

BONUS: These are an amazing alternative to the NSAIDs I recommend you eliminate, delivering nearly all of the positive effects (plus a myriad of other health benefits) without the negative health impacts.

4. Number four treatment for ankylosing spondylitis: Take Sulfasalazine (the enteric coated kind)

Bet you thought I was gonna hit you with another anti-drug recommendation, huh?  Listen, I’m about what WORKS best in the LONG run, not about what's a drug and what isn't.  

This particular drug has been in use for decades, it really seems to help people, and -- this the the important part -- according to studies and long term use reports, it carries very minimal long term risks.

What is it?  Sulfasalazine, as the name implies, is a sulfa based drug that acts as a DMARD (disease modifying rheumatic drug), reducing inflammation and possibly preventing the progression of the disease (fusion, etc.)

How does it work?  Strangely, we don’t know.   What we do know, however, is that the drug doesn’t appear to directly reduce inflammation systemically. 

Instead, the most plausible theory is that it reduces inflammation directly in the gastrointestinal system (it’s used for ulcerative colitis, which is inflammation of the colon), causing a reduction in gut permeability, and thus, lowered disease symptoms.

Noticing a trend here?  (Hint: Your gut is all important in making your ankylosing spondylitis better).

Why enteric coated?  This slows absorption, making the effect stronger.  I take 1000mg twice daily, and if a pharmacy screws up and gives me the wrong version, I notice a difference between the two (non-enteric versus enteric coated).  

I have virtually no ongoing symptoms, but if I get the wrong type of sulfasalazine, I notice I have slightly less tolerance for "questionable" foods that have very low starch content (dark chocolate for example)

How do you get it?  Your doctor can prescribe this to you.  They may question its efficacy (because they don't understand that managing gut inflammation is essential), but in general if you insist they are happy to prescribe it to you as it's extremely low risk.

5. My last "treatment" for ankylosing spondylitis: Biologic drugs like Humira, Enbrel, and Remicade

What are they, and how do they work?  Biologics are a specific class of drugs that modulate the immune system by reducing the signaling of an inflammatory cytokine (a type of signaling molecule) called tumor necrosis factor alpha (TNFa).  


Since this cytokine (TNFa) promotes the inflammation that drives the pain and disease progression of ankylosing spondylitis, reducing its effects can dramatically reduce the signs and symptoms of ankylosing spondylitis.

Now, it's likely you've heard of this class of drugs because your doctor may have already recommended them for you, or you've seen ads on TV (if you're in the U.S. anyway).

These are the big guns, and they have risks, but for most people they do work.  I don’t think they should be used until all other options  have been exhausted (especially diet and the other 3 recommendations I've already made), but if that’s the situation you’re in, I think they are worth the risk.

Now, I don’t have hard, scientific evidence to back this up, but it’s my view biologics are the most effective pharmaceutical intervention because (you guessed correctly) they actually promote healing of the gut over time.  More on that in a second, first, the bullet points.

If they work so well, why not just take these and get on with your life?  

It’s a good question, and there are three answers.  

First, because TNFa is involved in mediating the part of your immune system that fights off infections and destroys cancer cells, taking this class of drug can increase your risk of infection and certain kinds of cancers, especially in those “at risk” individuals with weaker immune systems.

Second, because you may be able to get back to feeling better without these drugs by addressing the ROOT cause of your autoimmune disease — your gut — through non-drug interventions like diet (see my earlier emails)

Third, because many people, even after taking these biologics don’t feel 100% better, and its only through a combination of diet, lifestyle, and drugs that they get back to feeling totally normal.

Why do I think that gut healing is the real “mechanism of action” of biologics?

  1. These drugs often take up to 6 weeks to start working, and I think that’s because that’s how long it can sometimes take for someone’s gut to heal.
  2. They are used in inflammatory gastrointestinal diseases like Crohn’s, Ulcerative Colitis, and IBS, and studies have shown significant healing of the lesions that are common in these diseases.  Healing of lesions = less permeability = less systemic inflammation.

It’s just my theory, so take it with a grain of salt, but as you can probably tell, I’m a believer in the importance of gut health in making your ankylosing spondylitis a distant memory.

How do you get a prescription?

Firstly, as I said above, I would STRONGLY encourage you to exhaust all other possible options before seeking a prescription for biologics due to the risks.  

Not only will you be certain they're the right move at that point, but your chances of having them work and get you to being completely pain free will be higher (at least, that's what my readers have reported over and over).

That said, nearly any good rheumatologist in the developed world (US, Europe, Australia, Canada, etc.) will recommend these relatively soon in treatment to ensure minimal long-term damage from disease progress.

Now, we have just one list thing to talk about...


How should you integrate these ankylosing spondylitis “treatments” into your life? 

Now you know what to do, but how do you decide what to try first, and what are the practical steps in doing so? 

That’s a big question, and beyond the scope of these emails (which were already WAY too long).  

Put simply, I’d try each step one at a time, stacking them on top of each other until you feel the way you’d like to.

However, if you want a more “step by step” outline, including specific and exact diet recommendations, recipes, and even exercises you can do, again, I’d encourage you to check out my book Living A.S. Free.

It's been a pleasure sharing what I've learned, and I wish you all the best on your journey back to health.  

If I can support you in any way, please don't hesitate to ask.