Review: Treatment Options for Spondyloarthritis

Treatment options for patients with axial spondyloarthritis (SpA) have progressed over the past few years, but non-steroidal anti-inflammatory drugs (NSAIDs) remain the first line of defense against most axial spondyloarthritis (SpA) related diseases (except for psoriatic arthritis) followed by TNF blockers.

The development of anti-IL 17 and other biologics will eventually broaden therapeutic options for patients with axial spondyloarthritis (SpA), so physicians should learn more about the risks and benefits of combining NSAIDs with TNF blockers or combining TNF blockers with IL-17 inhibitors, write the authors of a review published in the April 7 issue of Nature Reviews Rheumatology. 

Spondyloarthritis, both in terms of axial and peripheral, were included in the review with peripheral SpA defined as having asymmetric, monoarticular or oligoarticular arthritic patterns of the lower limbs, enthesitis and dactylitis - all of which can occur in association with psoriasis, inflammatory bowel disease and psoriatic arthritis.  [[{"type":"media","view_mode":"media_crop","fid":"48885","attributes":{"alt":"©SebastianKaulitzki2/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_7100731957775","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5867","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©SebastianKaulitzki2/Shutterstock.com","typeof":"foaf:Image"}}]]

Joachim Sieper and Denis Poddubnyy, both of Charite Universitatsmedizin Berlin in Germany, highlighted the latest data on the effective treatment of both the axial and peripheral forms of the disease.

Here's what's known about potential treatments, according to Sieper and Poddubnyy:

NSAIDS (diclofenac, ibuprofen, naproxen, celecoxib and etoricoxib):  Highly effective in reducing back pain in axial spondyloarthritis, though continuous use does not appear to prevent relapse in patients who are in remission. In one 2014 study cited in the review, patients who were administered a combination of infliximab and 1,000 mg of naproxen per day (or alone or placebo) – after six months, 62 percent of patients reached partial remission. The study showed that early disease state responded better to NSAID therapy. Another study cited in the review showed that NSAIDs in general have similar efficacy in treating axial SpA and adverse effects short term. NSAIDs have also been associated with moderately elevated risk of cardiovascular and gastrointestinal events.

Conventional DMARDs (methotrexate, sulfasalazine or leflunomide):  Not effective in axial spondyloarthritis, but can be useful in patients with both axial and peripheral disease. Research is underway to determine whether combining conventional DMARDs with biologics might make DMARDs more useful for treating axial spondyloarthritis.  

Glucocorticoids:  Systemic glucocorticoids are not recommended for axial SpA.

TNF inhibitors:  Several studies have shown that TNF-blocker therapy leads to a “good’ or “very good” improvement of clinical symptoms, CRP levels, and inflammation of the sacroiliac and spinal joints. These studies included only patients with ankylosing spondylitis who were enrolled in trials for infliximab, etanercept, adalimumab, golimumab and certolizumab pegol.

Favorable clinical trials have led to the approval of etanercept, adalimumab, golimumab and certolizumab pegol for the treatment of nonradiographic axial spondyloarthritis in the European Union. These treatments have not been approved by the FDA, in part because of concerns about overtreatment of patients who would go into remission without TNF blockers. However, some data suggests that spontaneous remission is rare in patients with nonradiographic axial spondyloarthritis; studies are ongoing.

Other biologics:  The IL-1 receptor antagonist anakinra and the T-cell modulator, abatacept, performed no better than placebos in small open-label trials. Monoclonal antibodies Tocilizumab and sarilumab performed no better than the placebo in double-blind studies. A small, prospective study on rituximab showed "equivocal" results, suggesting the need for a clinical trial. However, monoclonal antibodies against IL-17, IL-23 or the p40 protein have been shown to be moderately effective in treating psoriatic arthritis.

Secukinumab:  The biologic secukinumab, which targets IL-17, has been shown to be effective in ankylosing spondyloarthritis in two placebo-controlled phase III clinical trials. The response rate was similar to that of TNF-blockers, and the biologic also seemed effective in patients who did not respond to or had contraindications for TNF blockers. However, questions remain as to whether a second TNF blocker would be a more effective backup that secukinumab, should the first TNF blocker fail, and whether there are differences in the patient subgroups who might respond to secukinumab versus TNF blockers.­­­

References:

Sieper J, Poddubnyy D.

“New evidence on the management of spondyloarthritis.” 

Nat Rev Rheumatol Nature Reviews Rheumatology

 2016;12(5):282–295