Page 813 - Clinical Immunology_ Principles and Practice ( PDFDrive )

784 Part six Systemic Immune Diseases

FiG 57.7 The “classic” course of ankylosing spondylitis, showing disease progression from shortly
after disease onset in 1947 until just before the patient’s death in 1973. The slight improvement
between 1972 and 1973 was as a result of his having undergone total hip arthroplasties.

TABLE 57.7 treatment of tHEraPEUtiC PriNCiPLEs
spondyloarthritis Treatment Principles for Medical Management of
• Patient education Spondyloarthritis
• Physiotherapy
• Medications • Patient education, regular exercise, smoking cessation, and physio-
• Nonsteroidal antiinflammatory drugs therapy should be initiated early in the disease course.
• Disease-modifying antirheumatic drugs • Nonsteroidal antiinflammatory drugs (NSAIDs) remain the “first-line”
• Sulfasalazine (especially for peripheral arthritis) treatment.
• Methotrexate (especially for psoriatic arthritis, psoriasis) • Disease-modifying antirheumatic drugs (DMARDs: sulfasalazine,
• Leflunomide methotrexate) are used for peripheral arthritis.
• Corticosteroids • Intraarticular/intralesional corticosteroid injections are administered.
• Systemic • Biological (anti–tumor necrosis factor [TNF], anti–interleukin-17 [IL-17]
• Intraarticular, intralesional agents) for axial disease refractory to NSAIDs, peripheral arthritis
• Biological agents refractory to DMARDs, and entheseal lesions refractory to NSAIDs.
• Tumor necrosis factor blockers • It is important to remember to treat coexistent/complicating conditions
• Interleukin (IL)-17/-IL-23 blockers (inflammatory bowel disease [IBD], psoriasis, osteoporosis, premature
• Treatment of osteoporosis atherosclerosis).
• Surgery
• Hip replacement
• Corrective spinal surgery
Other DMARDs. Although less well studied than sulfasalazine,
methotrexate has been shown to be effective in some but not all
studies of peripheral arthritis and psoriasis in patients with AS
Medical Treatment and other SpA. Its efficacy in treating axial SpA has not been
established.
Nonsteroidal Antiinflammatory Drugs The use of leflunomide in patients with SpA has not been
NSAIDs remain the starting point of treatment, and many well examined. Limited data suggest that it may be useful in the
patients will attain satisfactory symptom control with these agents treatment of peripheral joint involvement in SpA as well as PsA,
alone. There are no strong data to suggest the superiority of although not for axial involvement. Apremilast, an oral phos-
any specific NSAID in patients with SpA. NSAIDs when taken phodiesterase 4 inhibitor, has been shown to be effective in
regularly (not on an as-needed basis) and at full antiinflam- psoriatic arthritis but not in AS. 43
40
matory doses retard the radiographic progression of AS, an Corticosteroids. Although not well studied in patients with
41
observation that has recently been replicated. COX-2 antagonists AS, many clinicians add low-dose glucocorticoids to the manage-
are recommended mainly for patients with proven peptic ulcer ment of active SpA where NSAIDs or DMARDs fail to achieve
disease. Of concern is the association of the use of NSAIDs with a satisfactory response. On occasion, pulse steroids have also
flares of colitis, suggesting they should be used with care in been utilized. Given the lack of controlled data as to their
this setting. effectiveness, the side effects of long-term glucocorticoid therapy
(including osteoporosis, a major cause of morbidity in AS patients,
Disease-Modifying Antiinflammatory Drugs and possible worsening of psoriasis), and the emergence of more
Sulfasalazine. The efficacy of sulfasalazine in the treatment effective treatments, their use is not recommended unless more
of peripheral joint involvement in AS and other SpA has been effective treatments are not available.
shown in several controlled trials, including two large multicenter
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studies in the United States and France. It is not efficacious in Intraarticular/Intralesional Corticosteroids
axial disease. Coincident with improvement in peripheral arthritis Intraarticular and peritendinous injections of depot steroid prepa-
is a fall in acute-phase reactants, such as the ESR and CRP. rations are frequently employed by clinicians for symptomatic