Axial spondyloarthritis

Introduction

  • Axial spondyloarthritis (SpA) affects approximately 23.8 and 31.9 per 10 000 people in Europe and North America, respectively, and is more common in men than women1
  • Axial SpA represents a group of chronic inflammatory diseases that involve the axial skeleton and peripheral joints and share common clinical, genetic, and pathophysiological features2
  • Pharmacological treatments include non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, and biologic disease-modifying anti-rheumatic drugs (bDMARDs)2,3
  • Axial SpA treatment can cost more than EUR 20 000 per year, per patient4

Burden of axial SpA

Early diagnosis is key

Axial SpA can lead to irreversible damage.5

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

Common and extra-articular manifestations of axial SpA2

Common manifestations:
Extra-articular manifestations:
  • Back pain
  • Stiffness
  • Arthritis
  • Enthesitis
  • Dactylitis
  • Anterior uveitis
  • Psoriasis
  • Inflammatory bowel disease

Axial SpA causes inflammation and bone fusion

Axial SpA is caused by an increased amount of interleukin (IL)-23, which in turn stimulates IL-22 and IL-17. These activate tumor necrosis factor alpha (TNF-α), which stimulates proliferation of osteoblasts, bone formation, and resorption (via inflammation), and can lead to bone fusion, or ankylosis.6 

HLA, human leukocyte antigen; IL, interleukin; TNF, tumor necrosis factor.

Adapted from Lories and McInnes, 2012.6

Impact

Axial SpA impacts quality of life

  • Symptomatic axial SpA is associated with pain, sleep problems, disability, and dependency, all of which may adversely affect well-being and quality of life7
  • Both the direct costs (medications, outpatient visits, hospitalizations, home help, and alternative treatments) and indirect costs (lost productivity in the workplace and disability) associated with axial SpA are significant4

Treatment

Assessment of SpondyloArthritis international Society (ASAS) treatment recommendations for axial SpA

 

csDMARD, conventional synthetic DMARD; NSAID, non-steroidal anti-inflammatory drug; TNF, tumor necrosis factor. 

Adapted from Van der Heijde et al, 2017.

Biologic therapies: anti-TNFs

Guidelines recommend that anti-TNFs are used in the following treatment scenarios:3

ASDAS, Ankylosing Spondylitis Disease Activity Score; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; NSAID, non-steroidal anti-inflammatory drug; DMARD, disease-modifying anti-rheumatic drug.

Adapted from Van der Heijde et al, 2017.3

Biologic therapies: anti-IL-17A

A further biologic treatment option is now available for the treatment of axial SpA: IL-17A inhibitors. Currently, only secukinumab is approved, but several other agents are in late stage development. The use of IL-17 inhibitors should be avoided in patients with active inflammatory bowel disease.3

Guidelines

Recommended treatment for axial SpA

The 2016 update of the ASAS-European League Against Rheumatism recommendations reflect the recent treatment guidelines for axial SpA:3

  • Treatment tailoring is the main focus
  • Treatment goals include maximizing health-related quality of life and preventing progressive structural damage
  • Optimal management should combine non-pharmacological and pharmacological treatments; multidisciplinary management is recommended
Tailor treatment according to:
Current manifestations (axial, peripheral) Level of symptoms General clinical status
Disease monitoring
Patient-reported outcomes Clinical parameters Laboratory tests/imaging
Non-pharmacological treatment
Patient education Regular exercise Physical therapy
Comorbidities
NSAIDs have a central role
Analgesics may be considered for residual pain
Limited use of corticosteroids
bDMARDs in patients who fail conventional treatments; current practice is to start with anti-TNF therapy
In case of anti-TNF failure, switch to another anti-TNF or anti-IL-17A
Surgery should be considered in patients with refractory pain or disability and radiographic evidence of structural damage

bDMARD, biologic disease-modifying anti-rheumatic drug; IL interleukin; NSAID, non-steroidal anti-inflammatory drug; TNF, tumor necrosis factor.

Adapted from van der Heijde et al, 2017.3

 

Support

Additional information

You can find additional information about axial SpA by following these links:

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

National Ankylosing Spondylitis Society:
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):650-57.

2. Proft F and Poddubnyy D. Ther Adv Musculoskelet Dis. 2018;10(5-6):129–39.  

3. Van der Heijde D, et al. Annals of the Rheumatic Diseases 2017;76:978-91.

4. Reveille JD, et al. Am J Med Sci. 2012;343(5):371–74. 

5. Keat A, et al. Rheumatology. 2011;50:1936–39.

6. Lories RJ and McInnes IB. Nature Medicine. 2012;18:1018–19.

7. Sieper J, et al. Ann Rheum Dis. 2002;61(Suppl III):iii8–iii18.

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