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Review: Axial Spondyloarthritis Treatment Guidelines

Updated EULAR guidelines for axial spondyloarthritis raise more questions than answers about biologic therapies and treat-to-target strategies, a review suggests.

The recent update to the 2009 European League Against Rheumatism treatment guidelines for axial spondyloarthritis provides a useful framework for rheumatologists.

However, the French researchers Daniel Wendling and Clement Prati suggest, “The guidance on use of biologic therapies and treat-to-target strategies seems to raise more questions than it answers.”

The new recommendations provide direction for a research agenda aimed at answering questions that have arisen from this endeavor.

New drugs along with new management concepts such as treat-to-target, tight control and a therapeutic window of opportunity have prompted the Assessment of Spondyloarthritis International Society in conjunction with the European League Against Rheumatism to provide an update to previous recommendations.

The authors present the highlights of this update in a recent news and views article in Nature Reviews: Rheumatology.

Highlights for Physicians

1) This update includes non-radiographic axial spondyloarthritis for the first time. The authors state “Non-radiographic axial spondyloarthritis is a reality and should not be ignored.”

2) There are new recommendations for the initiation of a biologic DMARD therapy. The update provides a clear framework for initiating and evaluating biologic DMARD therapy. Emphasis is placed on objective signs of inflammation such as elevated C-reactive protein and the results of MRI tests.

3) 2016 recommendations include the new class of interlukin-17A drugs, which remain second line drugs after TNF inhibitors.

4) The update takes cost into account for the first time since biologic DMARDs are expensive. Biosimilar drugs may also have economic impact and implications with regards to prescribing patterns for biologic DMARDs.

5) The new guidelines address the possibility of tapering the dose and frequency of anti-TNF drugs, which many rheumatologists already do.

Unmet Needs and Unresolved Questions

The 2016 recommendations state “treatment should be guided according to a predefined treatment target.” However, the authors point out that the guidelines do not supply a clear definition of what treatment targets should be.

The authors suggest that validated criteria describing low disease activity should be used as treatment targets.

  • The ankylosing spondylitis disease activity score is an example with a value of less than 1.3 serving as the inactive disease target.
  • A second target could be maintaining normal activities and capacities.

Data are lacking with regards to the economic impact of long-term biologic treatments. The authors suggest that studies will be needed comparing the efficacy and cost effectiveness of various DMARDs.

Studies are needed look at the treat-to-target strategies and confirm or deny the existence of an early window of opportunity for treating axial spondyloarthritis.

With new drug therapies emerging, strategies optimizing the use of anti-tumor necrosis factor drugs should develop in real time with strategies for monitoring drug and disease activity. Structural effects caused by non-steroid drugs and biologics should be studied as well.

The authors conclude by saying “beyond any new treatments or management recommendations, the crucial point in clinical practice remains the early diagnosis of axial spondyloarthritis and the identification of conditions that might interfere with evaluation of the disease, such as fibromyalgia.”

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Daniel Wendling and Clement Prati. Fine Tuning the Management of Axial Spondyloarthritis. Nature Reviews Rheumatology. Published first online 23 February 2017 13,199–200 (2017) doi:10.1038/nrrheum.2017.24