Therapy for ankylosing spondylitis: new treatment modalities

November 4, 2002

J. Braun, Maxime Breban, Walter P. Maksymowych

p 631-651, Volume 16, Number 4, September 2002

Abstract

The therapeutic options for patients suffering from the more severe forms of

spondyloarthritis (SpA) have been rather limited in recent decades. There is

now accumulating evidence that anti-tumour necrosis factor (anti-TNF)

therapy is highly effective in SpA, especially in ankylosing spondylitis

(AS) and psoriatic arthritis (PsA). Based on the data recently published on

more than 200 AS patients, and more than 100 PsA patients, this treatment

seems to be even more effective than it is in rheumatoid arthritis (RA). The

two major anti-TNF-[alpha] agents currently available, infliximab

(RemicadeR) and etanercept (EnbrelR), are approved for the treatment of RA

in Europe and in the USA. The situation in SpA is different from RA because

there is an unmet medical need, especially in AS, because disease-modifying

anti-rheumatic therapy is not available for severely affected patients.

Thus, TNF blockers might even be considered first-line immunosuppressive

treatment in patients with active AS who are not sufficiently treated with

non-steroidal anti-inflammatory drugs (NSAIDs). For infliximab, a dose of

5 mg/kg was required, and intervals between 6 and 12 weeks were necessary

for constant suppression of disease activity - a major aim also for

long-term treatment. However, it remains to be shown whether patients

benefit from long-term therapy and whether radiological progression and

ankylosis can be stopped. The optimal doses of infliximab might well be

determined individually. Allergic reactions and increased susceptibility to

tuberculosis are rare side-effects which need to be recognized early. As it

stands now, the benefits of anti-TNF therapy in AS seem to outweigh these

shortcomings. The efficacy of etanercept was first demonstrated in PsA. A

double-blind study has now been performed in AS - with similar results.

There is preliminary evidence that both agents also work in other SpA such

as undifferentiated SpA. Hopefully, both agents will be approved soon for

the short-term treatment of severe SpA. In parallel, studies should be

performed to document the long-term efficacy and safety of this treatment.

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