Clinical Management of Ankylosing Spondyloarthritis

Allan Gibofsky, MD: The first therapy for the treatment of ankylosing spondylitis, and the first objective is, of course, relief of pain. Nonsteroidals are generally used at first in order to provide some acute pain relief. These were the agents that were used most widely before the newer agents and even the conventional synthetics—such as methotrexate, leflunomide, and sulfasalazine—came along. The next step is the use of these conventional synthetics, usually alone or in combination and often together with the anti-inflammatory nonsteroidals. Finally, the next step would be to advance the patient to a biologic agent, and all of the 5 TNF (tumor necrosis factor) inhibitors are approved for the treatment of ankylosing spondylitis, as is the IL-17 inhibitor secukinumab. In general, we tend to start with the TNF inhibitors because we have the greatest experience with them. And when they work, they work quite well. In patients who do not respond to one TNF inhibitor, the physician may switch to another because we often find that not all patients respond to the same TNF inhibitor, nor do they respond all the time. We can have 2 patients in the waiting room on the same medication. One swears by it, and one swears at it. Hence, we need a variety of choices. Finally, we have newer agents, such as IL-17 inhibitors, that can be used either as the first biologic or, more often, are being used after one or more TNF agents have been used and the patient has had an inadequate response.

The TNF inhibitors have really changed the landscape for the treatment of ankylosing spondylitis, and when used appropriately, they have significantly improved a long-term outcome in these patients. We tend to want to use them earlier rather than later because there has been such a dramatic effect on controlling the inflammation that leads to the clinical manifestations, as well as the long-term consequences, of untreated or undertreated inflammation, such as the potential development of heart disease and malignancy.

The earlier we control inflammation, the better it is that we will be able to reduce the likelihood of a long-term consequence of untreating or undertreating inflammation, such as heart disease or malignancy. Ideally, the patient with ankylosing spondylitis who is still symptomatic, after the use of a conventional synthetic, should be immediately placed on a biologic agent—in particular, a TNF inhibitor. There ought to be no barrier or impediment to their use because of their great role in affecting the outcome and improving signs and symptoms, improving patient reported outcomes, and decreasing the structural progression. Unfortunately, there are often access issues that limit their early availability.

But as to the question regarding who the appropriate candidate for biologic therapy is, I think it would be more appropriate to say that all patients are candidates, unless there is some reason not to give it, such as chronic infection or tuberculosis or malignancy, in which case you treat the contraindication and then you go on to treat with the biologic agents of the TNF class. So, putting all that together, we now have the opportunity for treating patients according to their symptoms, according to their presentation, and based on whether or not they have comorbidities that would affect the choice of one or another agent.

In patients who have peripheral joint disease as a manifestation of either their psoriatic arthritis or their ankylosing spondylitis, then selective glucocorticoid injections may be helpful (in some instances, for limited periods of time). If patients have multiple joints involved, however, corticosteroid injections are not going to be as effective because you’re not going to inject all the joints that the patients have involved (particularly if they are multiple small joints). We rarely inject spinal joints because that is much more difficult to do and the evidence that injection of a spinal joint will have clinical efficacy is really quite limited. For that reason, we tend to reserve corticosteroid injections in psoriatic arthritis and ankylosing spondylitis to the peripheral joints, where appropriated, and in individuals with few joints involved.

Transcript edited for clarity.