How is Axial Spondyloarthritis treated
Which medications are helpful in the management of axSpA?
Although there is no cure for axSpA, most patients can be managed by controlling inflammatory symptoms and participating in an exercise program to minimize deformity and disability. The following modalities are helpful:
NSAIDs. These may improve symptoms to a much greater degree in axSpA than in noninflammatory back pain. Use of continuous celecoxib has been associated with a decrease in radiographic progression in a randomized controlled trial and observational studies. The data for other NSAIDs is less compelling, although use of high doses of other NSAIDs may show similar results. Simple analgesics can be added for additional pain relief but should not be used as primary therapy. High-dose NSAIDs for 2 weeks is considered an adequate trial, and trials with two NSAIDs are recommended prior to more aggressive therapy.
Anti-TNF therapy. These agents are highly effective in reducing the inflammatory component of axSpA including spinal mobility, function, peripheral synovitis, enthesitis, and uveitis while improving quality of life. The highest response rates (ASAS-40 in 50% of patients) have been observed in younger patients with shorter disease duration and elevated CRP, but patients with advanced disease may also benefit from this therapy, especially if CRP is elevated. Concomitant therapy with methotrexate is not recommended, though some studies suggest longer drug persistence only for infliximab with methotrexate. Anti-TNF agents should be employed for active (BASDAI ≥4) axSpA patients with predominant axial manifestations despite adequate trials of NSAIDs. The effect of anti-TNF agents on radiographic progression is controversial. Observational data suggests that early (within 10 years of symptoms) and prolonged (>3.9 years) use decreases syndesmophyte formation. Monoclonal anti-TNF agents are favored in patients with uveitis or inflammatory bowel disease. Very limited data does support the use of biosimilars.
Anti-IL17 α therapy. Secukinumab and ixekizumab have demonstrated similar efficacy to anti-TNF agents for patients with AS.
Peripheral joint disease. Sulfasalazine (1500 mg twice a day), and to a lesser extent, methotrexate, may be beneficial in patients with NSAID-resistant peripheral arthritis, but have no role in treating sacroiliitis, spondylitis, or enthesitis, according to most studies. Other conventional synthetic antirheumatic medications (leflunomide, apremilast) are not recommended. Very preliminary data has been somewhat supportive of tofacitinib (5 mg twice a day) in axial disease.
Other biologics. Ustekinumab at high doses may exhibit some beneficial effect. Abatacept, tocilizumab, anti-IL-23 agents, and rituximab are not effective for axSpA.
Corticosteroids. Oral corticosteroids have no value in the treatment of musculoskeletal aspects of axSpA, except in specific circumstances (e.g., pregnancy). Local corticosteroid injections are useful in the treatment of enthesitis, peripheral synovitis (≤2 joints), and recalcitrant sacroiliitis.
Other treatments. Bisphosphonates and calcium/vitamin D replacement should be considered in axSpA patients with osteoporosis. Anterior uveitis can usually be managed with dilation of the pupil and corticosteroid eye drops. AxSpA patients should undergo fall evaluations and counseling.