There have been major advances in the diagnosis and treatment of axial spondyloarthritis (axial SpA) which includes ankylosing spondylitis (AS) and non-radiographic axial SpA (nr-axSpA).

In AS, sacroiliac joint abnormalities are observed by conventional x-rays but not in nr-axSpA. Ossification in the spine is the primary pathology in AS resulting in progressive irreversible structural damage. Until recently no treatments halted disease progression or led to disease remission. This is changing, increasing the emphasis on early detection.

Dr Ai Tran, Rheumatologist, Murdoch

Dr Ai Tran, Rheumatologist, Murdoch

First line therapies for AS are physiotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs). Regular physical exercise and patient education form the cornerstone of treatment. A Cochrane review highlighted that any exercise, whether supervised or home-based, was better than no exercise for improving movement and physical function.

NSAIDS can relieve symptoms including back pain and stiffness in up to 70-80% of patients, however, the potential cardiovascular and gastrointestinal toxicities should be taken into consideration. Its role in preventing radiographic progression in AS is yet to be established.

The biological era has transformed AS management. Tumour necrosis factor inhibitor (TNFi) therapy is currently available for patients who have persistently high disease activity despite conventional treatments.

In Australia the currently available TNFi therapies include adalimumab, certolizumab, etanercept, golimumab and infliximab. Biosimilar TNFi therapies have also become available slightly lowering the prices of biologics. This year, golimumab was the first TNFi to be approved for the use in nr-axSpA for patients with raised inflammation markers and MRI evidence of sacroiliitis.

Pooled data from 12 European registries including more than 24,000 patients with a baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of 59mm, show six months into treatment, 72% of patients scored less than 40mm. At one and two years into treatment, 75% and 77% achieved BASDAI scores below 40mm respectively. Importantly, the ability of TNFi therapy to reduce spinal radiographic progression in patients with axial SpA have also been demonstrated if used long term (over four years).

Up to 40% of patients do not respond to or are intolerant to TNFi therapy. Antagonism of the IL-17 cytokine made by Th17 cells is an alternative approach to the abrogation of inflammation. Secukinumab (a fully humanised IL-17A inhibitor) is the latest biological drug available for use in axial SpA. Studies show that Secukinumab can reduce spinal inflammation on MRI as early as week six in patients with AS with a low overall rate of spinal radiographic change over two years regardless of previous TNFi exposure

The overall safety profiles of biological drugs are acceptable and the benefits outweigh the risks enabling patients with axial SpA an enhanced quality of life and reduced disability

Key messages

  • Physiotherapy and NSAIDs are first line therapies for ankylosing spondylitis
  • Up to 40% of patients do not respond or are intolerant to TNF inhibitor therapy
  • Interleukin 17 inhibitor therapy is an approved treatment for patients with ankylosing spondylitis.

References available on request.

Questions? Contact the editor.

Author competing interests: nil relevant disclosures.

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