Update on the treatment of ankylosing spondylitis

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Update on the treatment of ankylosing spondylitis

http://dovepress.com/articles.php?content_id=1948

Therapeutics and Clinical Risk Management Issue:2007, Volume 3, Issue 6

Walter P Maksymowych

Heritage Medical Research Building, University of Alberta, Edmonton,

Alberta, Canada

Abstract: Non-steroidal anti-inflammatory agents (NSAIDs) remain the

mainstay of treatment for ankylosing spondylitis (AS) though one recent

trial suggests that continuous as opposed to on-demand use may be superior

in preventing progression of structural damage.

One particular NSAID, which is a highly selective cyclo-oxygenase 2

inhibitor, etoricoxib, may be superior to standard NSAIDs for AS.

Second-line agents typically used for rheumatoid arthritis appear to lack

efficacy.

Salazopyrin is only moderately effective in the subgroup of AS patients with

concomitant peripheral arthritis and not in those with purely axial disease.

A recent trial showed that there is no greater efficacy in patients

presenting early in their disease course.

Three anti-tumor necrosis factor alpha agents, infliximab, etanercept, and

adalimumab, are now available for the treatment of AS, the latest being

adalimumab. All possess similar clinical efficacy in phase III trials with

response rates of about 60%.

Imaging studies using magnetic resonance show substantial amelioration of

inflammatory lesions in the spine and sacroiliac joints.

There is as yet no evidence that any of these agents prevent progression of

structural damage.

One study that evaluated etanercept demonstrated no impact on damage

progression.

Increasing evidence points to the superiority of the two monoclonal

antibodies, infliximab and adalimumab, over etanercept for the treatment of

extra-articular manifestations typically seen in AS such as acute

anterior uveitis and inflammatory bowel disease.

All three agents can be used as monotherapy and concomitant methotrexate

appears to offer no advantages although insufficient doses have been used to

date.

Future studies should target patients earlier in their disease course as

well as those with adverse prognostic factors such as elevated serum

metalloproteinase 3 levels and radiographic evidence of spinal ankylosis.

Keywords: infliximab, etanercept, adalimumab, ankylosing spondylitis, NSAIDs