Seeking True Guidelines for Spondyloarthropathies

June 2, 2014

Watch for new guidelines later this year for conditions such as psoriatic arthritis and ankylosing spondylitis. Expert bodies say that in light of new drugs existing versions may be dangerously inadequate.

Deodhar, A. Axial spondyloarthritis criteria and modified NY criteria: issues and controversies. Clinical Rheumatology. Clinical Rheumatology  (2014) Online First May 17.  doi: 10.1007/s10067-014-2661-8.

Ward MM. Update on the American College of Rheumatology/Spondyloarthritis Research and Treatment Network/Spondylitis Association of America axial spondyloarthritis treatment guidelines project. Clinical Rheumatology. (2014) May 2014 [Online first May 10] DOI10.1007/s10067-014-2660-9

Even as two new biological treatments have been approved for spondyloarthropathies, including axial spondyloarthritis (axSpA) and ankylosing spondylitis (AS), rheumatologists still lack specific diagnostic criteria and treatment guidelines for these inflammatory spine diseases.

A report published online in May by Clinical Rheumatology reveals that classification criteria set years ago for AS and axSpA are routinely used for diagnosis in clinical practice -- even though neither are regarded as sensitive enough to identify patients with the earliest signs of axial inflammation.

The report points out that the 2009 Assessment of Spondyloarthritis International Society (ASAS) classification criteria for axSpA and the 1984 modified New York (mNY) classification criteria for AS both list characteristics of the diseases, such as sacroiliitis, that apply to groups of patients -- but do not apply to individual diagnoses.

This poses a risk that inadequately -- or even inaccurately -- diagnosed patients may receive powerful anti-rheumatic disease-modifying drugs (DMARDs) like tumor necrosis factor (TNF) inhibitors or the newly-approved phosphodieserase-4 inhibitor apremilast (Otezla) and the interleukin-12 and IL-23 blocker ustekinumab (Stelara).

Four TNF drugs are approved for axSpA, AS, and another member of the disease family, psoriatic arthritis (pSA): etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), and golimumab (Simponi).

Efforts are underway to address the issue by the American College of Rheumatology (ACR), the Spondyloarthritis Research and Treatment Network, and the Spondylitis Association of America.

A second online report in Clinical Rheumatology outlines the parameters being used by the groups to develop “specific, actionable recommendations that clinicians could readily apply in their practices.”

The collaborative project, begun in 2011, will use the ACR’s Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method, based on systematic literature reviews and quantitative evidence summaries, to draft guidelines for  the use of pharmacological interventions, rehabilitation, surgery, and preventive care, as well as disease monitoring in patients with AS and axSpA.

The new guidelines are expected be available later this year.