Is Early Use of TNFi in Spondyloarthritis Overkill or a Necessity? Save

Axial SpA (axSpA) is a chronic inflammatory disease that includes AS and non-radiographic axSpA (nr-axSpA). The debate persists over whether nr-axSpA is a separate diagnostic entity from early stage of AS, The natural evolution of either disease remains undetermined since a proportion of cases do not progress. These issues obscure whether early intervention has an impact in either.

An observational study has investigated the clinical disease course, including achievement of remission, of patients with nonradiographic axial SpA compared with those with AS. The German Spondyloarthritis Inception Cohort (GESPIC)  was set up in 2000 as part of the German Competence Network Rheumatology program and, as a national multicenter study (http://bit.ly/1IW5vSU). As part of the observational study, the patients with nr-axSpa or AS patients of a short disease duration were analyzed.

They studied 303 patients with axial SpA (158 patients with AS and a symptom duration of ≤10 years and 145 patients with nonradiographic axial SpA and a symptom duration of ≤5 years) who did not receive tumor necrosis factor (TNF) blockers during 2 years of followup . Patients with nonradiographic axial SpA were considered to be candidates for anti-TNF therapy at baseline if they had a BASDAI score of ≥4 and an elevated CRP level (>6 mg/liter). Similar criteria were applied to patients with AS in order for the groups to be comparable.

Based on criteria that included the CRP level, the proportion of patients who achieved a low disease activity state at year 2 was greater among those with nonradiographic axial SpA than among those with AS. Low rates of remission were observed in the absence of TNF blocker treatment for both groups.

The study concluded that relatively small numbers of patients with nonradiographic axial SpA and patients with AS included in this study (∼1% of each subgroup) would have achieved “spontaneous” remission over time after having active disease at baseline, indicating that the risk of overtreatment of patients with nonradiographic axial SpA with TNF blockers is small and not different from that in AS patients.