Ankylosing spondylitis (AS) is a chronic immune‐mediated arthritic condition affecting the spine that can result in disabling fusion of the vertebrae and sacroiliac joints. Genetics plays a more dominant role in conferring risk for AS than in most autoimmune diseases, as evidenced by a heritability greater than 90%. The
HLA‐B*27
gene allele represents the greatest single risk factor identified to date, and multiple theories have been proposed to explain its contribution to pathogenesis. Genomewide association studies in AS have revealed other key genetic players, such as the polymorphic
ERAP1
, and implicated specific immune pathways, notably the IL‐23/IL17 cytokine pathway. However, much of the genetic basis for AS remains to be explained, providing future challenges to researchers and hope for clinicians.
Key Concepts
Ankylosing spondylitis belongs to a group of related inflammatory conditions typified by spinal arthritis, extraarticular inflammation and high prevalence of the MHC class I allele HLA‐B*27.
Ankylosing spondylitis has unusually high heritability, suggesting a strong genetic basis.
HLA‐B*27 remains the greatest genetic risk factor identified to date.
Multiple theories have been proposed to explain the link between HLA‐B*27 and disease ranging from immune recognition at the cell surface to unusual characteristics of its biosynthesis.
Genomewide association studies (GWAS) have identified other MHC genes, non‐MHC key molecules and immune pathways that contribute to ankylosing spondylitis.
The relevance of one of the GWAS pathways, the IL‐23/IL‐17 pathway, has borne out in treatment efficacy of related monoclonal antibody therapy in patients.
The genetic overlap between ankylosing spondylitis, inflammatory bowel disease and psoriasis may explain the frequently observed gut and skin inflammation comorbidities in ankylosing spondylitis.
Most of the ankylosing spondylitis heritability (about 70%) remains unexplained.