Closing Thoughts on the Management of nr-AxSpA

Transcript: Sergio Schwartzman, MD: I’d like to thank all of you for this rich and informative discussion. But before I let you go, I’m going to ask you for a very brief concluding statement from this discussion. I’ll start with Atul.

Atul Deodhar, MD, MRCP: We have made huge progress within the last decade. We already mentioned that in 2009, the ASAS [Assessment in SpondyloArthritis international Society] classification criteria came, and we are now able to classify more for patients clinical trials. The same year, the NHANES study was done, which gave us an idea about the scope or the burden of the disease. Since then, between 2009 and 2020, we have had several drugs that can be used to improve the quality of patients’ lives, and there are so many new drugs coming onto the market.

My final thought is to look at this last decade and think how much progress we have made. At the same time, look ahead and see how much progress needs to be made. Points have been made about the education and the appropriate diagnosis along with not underdiagnosing, not overdiagnosing, and finding new therapies. The prevention of new bone formation is another area that we didn’t really touch upon. But that’s another area of active research going on. I think there is a lot of excitement in this area. We are about 10 years behind rheumatoid arthritis, but we are getting there.

Sergio Schwartzman, MD: Thank you. Tiffany, what about your concluding remarks?

Tiffany Westrich-Robertson: I would just like to say that if a person comes into any doctor’s office—a primary care physician, for example—and is exhibiting any signs of inflammatory back pain or is complaining about any of the joint issues or fatigue, and you notice that as a big indicator of having inflammatory response, please consider even if they are HLA-B27 negative, even if their bloodwork is somewhat normal. Please do that referral, and please have the rheumatologist continue to understand, as we said earlier, the spectrum of axial spondyloarthritis to include people like me who may not be so obvious based on radiographic images that something is amiss.

Sergio Schwartzman, MD: Thank you. Philip, concluding remarks?

Philip J. Mease, MD: I concur with everything that’s been said. I would add that this is a very exciting time for us in rheumatology because we have treatments that can be effective and can get patients into a state of remission or low disease activity. This is unlike when I was first coming into rheumatology practice in 1982, and they were still treating rheumatoid arthritis with gold injections. We were basically holding the hand of patients as they had increasing deformities, and the ankylosing spondylitis was untreatable except with ibuprofen.

The only 2 suicides that I have had in my practice were in 2 young male patients with ankylosing spondylitis, because the pain was unbearable. We’ve made huge strides. We want to bring those strides to the patients. The patients need to get to us to be diagnosed and have the option of having those types of treatments be effective for them. Even though there are issues with having enough rheumatologists to refer to, that’s an important area where we’re expanding the workforce with nurse practitioners and physician assistants. We’re educating them to recognize this important group of patients.

I also will emphasize that non-radiographic axial spondyloarthritis is a gender justice issue, that we now recognize there are as many women who are having this disease as men. We need to recognize that and get appropriate treatments to them as well.

Sergio Schwartzman, MD: Thank you. Those are all very positive comments, and I am actually going to conclude a little more on some of our challenges. I’d like to conclude by going through some of the unmet needs that we really addressed throughout this discussion. The first is that we’re still unsure about the natural history of this disease. Why do some patients with nonradiographic axial spondyloarthritis progress to radiographic disease and others don’t? The delay in diagnosis has gotten much better. We’ve gone from 10 to 12 years to 4 to 8 years for this whole group of disease states that we call spondyloarthritis. That’s a success. But it’s not anywhere near as much as a success as what we see in rheumatoid arthritis. We have now begun to dispel the myth that this is a disease of only man, yet even Tiffany exemplifies a patient told, “You can’t have this disease because you’re not a man.” Probably the 2 areas that were going to see the greatest changes in the near future, but which are currently unmet needs, is being much more active about addressing the comorbidities and the call manifestations of axial spondyloarthritis. The last huge unmet need is the question of biomarkers. We’re talking about making the diagnosis of the disease. Wouldn’t it be outstanding if we had a blood test that could do that? This could be predicting response to therapy, a biomarker that would potentially predict response to therapy, or disease activity measures. We did not touch on that at all in our discussion. But is there a laboratory way to determine disease activity so as to objectively adjust our therapies? With that, I’d like to close and thank all of you. You are all outstanding. Not only did I enjoy doing this, but I learned from it as well. Thank you all.

Atul Deodhar, MD, MRCP: Thank you, Sergio.

Tiffany Westrich-Robertson: Thank you.

Philip J. Mease, MD: Thank you.

Transcript Edited for Clarity