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Was ist gesichert in der Therapie der axialen Spondyloarthritis?

What is ascertained in the therapy of axial spondyloarthritis?

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An Erratum to this article was published on 15 January 2014

Zusammenfassung

Der neue Terminus axiale Spondyloarthritis (axSpA) schließt die klassische ankylosierende Spondylitis und die nichtröntgenologische (nr-)axSpA ein. Die Definition erfolgte 2009 über die Klassifikationskriterien der Assessment of SpondyloArthritis international Society (ASAS) für axSpA, bei denen neben chronischem Rückenschmerz und dem Nachweis von HLA-B27 das magnetresonanztomographisch nachgewiesene Knochenmarködem der Sakroiliakalgelenke (Osteitis) bzw. die definitiven Strukturveränderungen im Röntgenbild eine wichtige Rolle spielen. Die Kriterien können zum Teil auch für die Diagnosestellung verwendet werden. Dadurch lassen sich auch frühere Formen von axSpA erkennen. Neben den nicht selten erforderlichen physikalischen Therapiemaßnahmen steht die medikamentöse Behandlung mit nichtsteroidalen Antirheumatika (NSAR), lokalen Glukokortikoidinjektionen und Biologika [Blocker des Tumor-Nekrose-Faktors (TNF); die Grenzziehung zwischen den beiden Subgruppen ist letztlich arbiträr, hat aber aktuelle Bedeutung für die Therapie mit Biologika, da nicht alle TNF-Blocker für beide Indikationen zugelassen sind] in abgestufter Strategie im Vordergrund. Klassische Basistherapeutika wie Sulfasalazin und Methotrexat wirken eher bei peripherer Gelenkbeteiligung, nicht aber bei Enthesitis und Wirbelsäulenbeteiligung. Neben der Verbesserung von Schmerzen, Steifigkeit und Funktion ist die Verhinderung der Knochenneubildung (Syndesmophyten) ein wichtiges Therapieziel, das zum Teil durch die kontinuierliche Gabe von NSAR und längerfristig auch durch Anti-TNF-Therapie erreichbar scheint. Patienten mit erhöhten Werten des C-reaktiven Proteins profitieren am meisten von einer konsequenten medikamentösen Therapie.

Abstract

The new term axial spondyloarthritis (axSpA) includes classic ankylosing spondylitis and non-radiographic (nr-) axSpA. The definition was introduced in 2009 as part of the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA, where—apart from chronic back pain starting before the age of 45 years and the presence of HLA-B27—magnetic resonance imaging demonstrated bone marrow edema of the sacroiliac joints (osteomyelitis) or structural changes on x-rays may play an important role. These criteria can also be used for diagnosis. A major advantage of the new criteria is the identification of patients in early disease stages. In addition to physical therapy, drug treatment with steroidal anti-inflammatory agents (NSAIDs), corticosteroid injections, and biologics [blocker of tumor necrosis factor (TNF)] have all been shown to be effective, while conventional disease modifying drugs (DMARDs) such as sulfasalazine and methotrexate seem to work mainly for peripheral arthritis but not for enthesitis. Biologics are indicated when NSAIDs in optimal dosage have failed. Both these drugs have the potential to improve pain, stiffness, and function but they may also have an influence on new bone formation (syndesmophytes). NSAIDs need to be given continuously and biologics for longer periods of time. Patients with elevated C-reactive protein levels benefit most when treated consequently.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. J. Braun hat Honorare für Vorträge und Advisory Boards von folgenden Firmen erhalten: AbbVie, MSD, Janssen, Pfizer, VCA, Celltrion und Amgen. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Braun, J. Was ist gesichert in der Therapie der axialen Spondyloarthritis?. Internist 54, 1450–1458 (2013). https://doi.org/10.1007/s00108-013-3331-7

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