Should axial spondyloarthritis without radiographic changes be treated with anti-TNF agents?

Abstract

A spectrum of disease extends beyond the rigid confines of ankylosing spondylitis (AS). Axial spondyloarthritis (axSpA) encompasses non-radiographic axSpA (nr-axSpA) in individuals without established radiographic changes but with other clinical/imaging axSpA features and AS in those with definite sacroiliac joint changes on pelvic X-rays. A broad consensus about the management of nr-axSpA is emerging among clinicians, but the evidence base remains open to question. To explore whether nr-axSpA and AS should be treated similarly, we examined the literature on their prevalence, natural history, disease burden, and treatment. There is strong evidence that nr-axSpA and AS are expressions of the same disease. Approximately 10% of patients with nr-axSpA will develop radiographic disease over 2 years; after >20 years, the figure may exceed 80%. Nr-axSpA patients have lower CRP and less spinal inflammation on MRI than AS patients but similar disease activity, pain, and quality-of-life impairment. Most patients with nr-axSpA manage well with conservative treatment, but a minority has severe disabling symptoms. Anti-TNF therapy has demonstrated similar efficacy and safety in nr-axSpA and AS. Current evidence does not clearly indicate that anti-TNF treatment can inhibit or limit bony progression of AS, the basis of conservative and anti-TNF treatment is control of symptoms and function. For some patients with nr-axSpA, the need for powerful treatments is as great as in some with AS; thus, treatment of axSpA should be consistent across the axSpA spectrum with anti-TNF agents being available, irrespective of radiographic change, according to the same criteria as those applied to AS.

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Acknowledgement

We are grateful to Dr. Stefan Siebert for helpful comments on the manuscript. Editorial/medical writing support was provided by Donna McGuire of Engage Scientific Solutions and was funded by Pfizer Inc.

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This work was supported by Pfizer.

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Correspondence to Andrew Keat.

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AK has received research funding from Abbvie and Pfizer and payments for speaking, chairing and attending ad hoc advisory boards from Abbvie, MSD, Biogen, Novartis, Pfizer, and UCB; ANB has received advisory board fees from Abbvie Ltd, MSD, Novartis, Pfizer, and UCB, research grants from Pfizer, and teaching honoraria from Abbvie Ltd, Pfizer, and UCB; KG has received speaker fees, consultancy fees, educational grants, and research funding from Abbvie, Pfizer, MSD, Napp, Novartis, and UCB; HMO has received grants and/or honoraria from Abbvie, Celgene, Jannsen, MSD, Novartis, Pfizer, and UCB; RS has received advisory board fees from Abbvie, MSD, Novartis, Pfizer, and UCB, research grants from Pfizer, and teaching honoraria from Abbvie, Pfizer, and UCB; TE is a Pfizer employee and owns stock options from Pfizer.

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Keat, A., Bennett, A.N., Gaffney, K. et al. Should axial spondyloarthritis without radiographic changes be treated with anti-TNF agents?. Rheumatol Int 37, 327–336 (2017). https://doi.org/10.1007/s00296-016-3635-8

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Keywords

  • Axial spondyloarthritis
  • Ankylosing spondylitis
  • Epidemiology
  • Burden of illness
  • Non-steroidal anti-inflammatory drugs
  • Tumour necrosis factor