Key Points
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Remission and low disease activity should be primary treatment targets for all patients with spondyloarthritis (SpA)
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NSAIDs are the first-line treatment for SpA; TNF blockers are indicated for patients with axial SpA who do not respond to NSAIDs or in whom NSAIDs are contraindicated
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Patients with nonradiographic axial SpA should have MRI evidence of inflammatory changes or elevated C-reactive protein levels to receive anti-TNF treatment
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Despite the good anti-inflammatory activity of NSAIDs and TNF blockers, insufficient data exist about whether these drugs can prevent or retard progression of structural spinal damage in axial SpA
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The IL-17 antagonist secukinumab is a new treatment option for patients with ankylosing spondylitis
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Treatment options in peripheral SpA (except psoriatic arthritis) are currently limited to NSAIDs, DMARDs and steroids; biologics are not officially approved for this indication
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for patients with symptomatic axial spondyloarthritis (SpA), who seem to respond best if treated early in the course of disease. The effect of NSAIDs on radiographic disease progression is less clear. Conventional disease-modifying antirheumatic drugs (DMARDs) are not recommended in the treatment of axial SpA, either alone or in combination with TNF blockers. Patients with nonradiographic axial SpA (nr-axSpA) seem to respond as well to TNF blockers as do patients with radiographic axial SpA (ankylosing spondylitis (AS)). However, patients with nr-axSpA should, in addition to a high severity of symptoms, also have objective signs of inflammation, detectable by MRI or by C-reactive protein testing, to be treated with TNF blockers. Whether early TNF-blocker treatment can retard new bone formation needs clarification. In clinical trials, anti-IL-17 agents and TNF blockers showed similar efficacy in patients with AS. The potential of IL-23 blockade for treatment of axial SpA needs to be further investigated. Treatment options for peripheral SpA have been much less thoroughly investigated than those for axial SpA. However, some data indicate that TNF blockers are effective for treating peripheral arthritis, enthesitis and dactylitis, the typical manifestations of peripheral SpA.
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Sieper, J., Poddubnyy, D. New evidence on the management of spondyloarthritis. Nat Rev Rheumatol 12, 282–295 (2016). https://doi.org/10.1038/nrrheum.2016.42
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DOI: https://doi.org/10.1038/nrrheum.2016.42
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