Ankylosing spondylitis

Introduction

  • Ankylosing spondylitis (AS) affects approximately 23.8 and 31.9 per 10,000 in Europe and North America, respectively, and is more common in men then women1
  • Pharmacological treatments include:
    • Non-steroidal anti-inflammatory drugs (NSAIDs; first line)2
    • Analgesics2
    • Corticosteroid injections2
    • Disease-modifying antirheumatic drugs (DMARDs)2
    • Biologic therapies: anti-tumour necrosis factor (anti-TNF)2 and anti-intereukin-17A (anti-IL-17A)3 monoclonal antibodies
  • AS treatment can cost over £6,000 (approximately €7,000) per year, per patient4

Burden of as

Early diagnosis is key

AS can lead to irreversible damage.5

AS typically begins during young adult life, and symptoms may interfere with education, professional development, and social relationships.5

Main symptoms and complications of AS

Common symptoms:6Complications:6
  • Pain
  • Stiffness (especially in the lower back)
  • Tiredness
  • Heart valve leakage
  • Lung tissue scarring
  • Vertebral fusion
  • Spinal fractures
  • Nerve damage
  • Osteoporosis

AS causes inflammation and bone fusion

AS is caused by an increased amount of interleukin (IL)-23, which in turn stimulates IL-22 and IL-17. These activate TNF-a, which stimulates proliferation of osteoblasts, bone formation and resorption (via inflammation), and can lead to bone fusion, or ankylosis.7

Adapted from Lories and McInnes.7

Impact

AS impacts Quality of Life

  • Symptomatic AS is associated with pain, sleep problems, disability and dependency, all of which may adversely affect well-being and quality of life8
  • Both the direct (medications, outpatient visits, hospitalisations, home help, and alternative treatments) and indirect costs (lost productivity in the workplace and disability) associated with AS are significant9

Treatment

ASAS treatment recommendations for AS

Adapted from Braun et al.2

Biologic therapies: anti-TNFs

Guidelines recommend that Anti-TNF drugs are used only when:12

  • Diagnosis of AS has been confirmed
  • The patient has had active disease for ≥4 weeks and, with a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score ≥4 (0–10) accompanied by a positive expert opinion
  • They have had an adequate therapeutic trial of NSAIDs (two NSAIDs over a 4-week period in total at maximum recommended or tolerated dose unless contraindicated)

ASAS guidelines for anti-TNF use in AS

Adapted from Van der Heijde et al.12

Biologic therapies: ANTI-IL-17A

A further biologic treatment option is now available for the treatment of AS – secukinumab, an IL-17A inhibitor. It is indicated for the treatment of active AS in adults who have responded inadequately to conventional therapy.3

Guidelines

Recommended treatment for AS

The 2010 update of the EULAR recommendations reflect the recent treatment of AS:2

  • Treatment tailoring is the main focus
  • Patients should be started on a non-pharmacological approach
  • Anti-TNFs should be used if conventional therapies have not controlled symptoms
1. Tailor treatment according to:
Current manifestions (axial, peripheral) Level of symptoms General clinical status
2. Disease monitoring
Patient history Clinical parameters Lab tests / imaging
3. Non-pharmacological treatment
Patient education Regular exercise Help groups
4. Treat comorbidities
5. NSAIDs
6. Analgesics
7. Corticosteroids
8. DMARDs
9. Anti-TNFs
10. Surgery

Adapted from Braun et al.2

Support

Additional information

You can find additional information about AS by following these links:

NHS Choices:
http://www.nhs.uk/Conditions/Ankylosing-spondylitis/Pages/Introduction.aspx

National Ankylosing Spondylitis Association:
http://www.nass.co.uk

National Institute of Arthritis and Musculoskeletal and Skin Diseases:
http://www.niams.nih.gov/health_info/ankylosing_spondylitis/

1. Dean L, et al. Rheumatology. 2014;53(4):650-657.
2. Braun J, et al. Ann Rheum Dis. 2011;70:896-904.
3. Cosentyx® (secukinumab) Summary of Product Characteristics.
4. Kobelt G, et al. Rheumatology. 2004;43:1158–1166.
5. Keat A, et al. Rheumatology. 2011;50:1936–1939.
6. Arthritis Research UK. What is the outlook for ankylosing spondylitis (AS)? Available at: http://www.arthritisresearchuk.org/arthritis-information/conditions/ankylosing-spondylitis/outlook.aspx. [Last accessed August 2016].
7. Lories RJ, McInnes IB. Nature Medicine. 2012;18:1018–19.
8. Sieper J, et al. Ann Rheum Dis. 2002;61(Suppl III):iii8–iii18.
9. Reveille JD, et al. Am J Med Sci. 2012;343:371–374.
10. Wendling D. Expert Opin Pharmacother. 2004;5:1497-507.
11. Toussirot E. Expert Opin Pharmacother. 2011;12:2469-2477.
12. Van der Heijde D, et al. Ann Rheum Dis. 2011;70:905–908.

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