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CHaPtEr 57 Spondyloarthritis 785

relief of local flare-ups, although they have not been extensively infusion of a chimeric mAb to TNF-α (infliximab) at 5 mg/kg
studied in controlled trials. Injecting around the Achilles of infliximab every 6–8 weeks; etanercept, given 50 mg subcutane-
tendon is generally not recommended because of the risk of ously weekly; adalimumab, which is used at a dose of 40 mg
tendon rupture. administered subcutaneously every other week; golimumab, at
a dose of 50 mg administered subcutaneously monthly; and
Antibiotics certolizumab, at either 200 mg administered subcutaneously
45
Early data suggested that a 3-month course of antibiotics in the every other week or 400 mg once a month. The onset of action
acute phase after disease onset may have a beneficial effect on is quite rapid, usually following the first infusion or injection.
46
the course of ReA, specifically in those with Chlamydia These agents are effective also in PsA and axial SpA. 45,47 Improve-
trachomatis–triggered ReA, but not in other patients. Recent ment was seen not only clinically but also radiographically, with
long-term follow-up data, however, suggest that tetracycline clearing of lesions suggestive of disease activity on MRI, and, in
treatment did not change the natural history of the disease. In studies extending >4 years, radiographically. Although earlier
another recent study, however, a 6-month course of azithromycin studies following up patients for 2 years did not demonstrate
and rifampin in the acute phase was found to have a beneficial that anti-TNF agents affect radiographic severity in AS, data
effect on the long-term prognosis, although this has not been from observational cohorts from North America and Europe
44
reproduced in all studies. It is clear that early antibiotic therapy spanning longer periods have shown they do, indeed, slow
for chlamydial genital infections can prevent ReA, although the radiographic progression, especially in those with shorter disease
same is not true for enteric pathogens. For patients at risk for duration treated for an extended period. 48
enteric infections and ReA, prophylactic antibiotics should be
considered. There is no evidence that antibiotics have any place Interleukin-17 Blockers (Secukinumab)
in the management of other SpA. Secukinumab is an anti–IL-17A mAb that has been shown to
control the symptoms of active AS in one phase II trial and two
TNF-α Blockers phase III clinical trials and has been approved by the FDA. The
49
This category of medications has been shown to be effective in impact of this medication on other disease features, such as
controlling inflammation and improving function in patients radiographic progression, remains to be determined.
with AS (Table 57.8). The use of TNF blockers in the treatment
of AAU is less clear, however. Recent data suggest they are useful, Surgical Treatment of AS Complications
1
at least those comprising monoclonal antibodies (mAbs). Cur- Because the hip is the joint most commonly involved in patients
rently five agents that have been approved for use by the Food with AS, total hip arthroplasty is the most common surgical
24
and Drug Administration (FDA) are in clinical use for the procedure. Heterotopic new bone formation may be a potential
treatment of AS in the United States, including infliximab, an problem.
Limited prevalence data suggest that patients with AS, even
those with mild disease, are at increased risk for vertebral fracture,
25
often resulting in neurological compromise. In general, halo
TABLE 57.8 international assessment in vest immobilization is recommended. Surgical intervention may
ankylosing spondylitis (asas) Consensus be necessary when neurological impairment is seen. The fixed
statement for the Use of anti–tumor kyphotic deformities seen in patients with advanced AS are of
Necrosis Factor (tNF) agents in Patients considerable distress to patients and may result in substantial
With ankylosing spondylitis (as) and axial functional impairment. A small minority of patients with AS
spondyloarthritis (aspa)* will seek surgical correction of their spinal deformities. In
general, open, polysegmental, and closing wedge osteotomies are
1. For the initiation of anti–TNF-α therapy: employed. Loss of correction is seen least commonly in closing
(a) A diagnosis of definitive AS by modified NY criteria or axial SpA
by ASAS criteria wedge osteotomy. In a meta-analysis of the literature between
(b) Presence of active disease for at least 4 weeks as defined by 1945 and 1998, an average correction of 37°–40° was seen, with
both a sustained Bath AS Disease Activity Index (BASDAI) of at perioperative mortality of 4% as a result of pulmonary, cardiac,
least 4 and an expert opinion based on clinical features, and intestinal problems. 50
acute-phase reactants, and imaging modalities
(c) Presence of refractory disease defined by failure of at least two
nonsteroidal antiinflammatory drugs during a single 4-week
period, failure of intraarticular steroids if indicated, and failure of CONCLUSIONS AND RESEARCH OPPORTUNITIES
a disease-modifying antirheumatic drug, preferably sulfasalazine,
in patients with peripheral arthritis
(d) Application and implementation of the usual precautions and ON tHE HOriZON
contraindications for biological therapy
2. For the monitoring of anti–TNF-α therapy: both the BASDAI and the Research Opportunities in
ASAS core set for clinical practice should be followed regularly Spondyloarthritis (SpA)
3. For the discontinuation of anti-TNF-α therapy: in nonresponders,
consideration should be made after 12 weeks’ treatment. Response • Improved understanding of pathogenetic mechanisms of SpA
is defined as improvement of: • Elucidation of the roles of non–major histocompatibility complex (MHC)
(a) At least 50% or 2 units (on a 0–10 scale) of the BASDAI genes in SpA
(b) Expert opinion that treatment should be continued • Definition of the link between gut inflammation and ankylosing
spondylitis (AS) triggering
*van der Heijde D, Sieper J, Maksymowych WP, et al. 2010 Update of the • Improved measures of treatment outcomes
international ASAS recommendations for the use of anti-TNF agents in patients with • Advances in biological therapies of SpA
axial spondyloarthritis. Ann Rheum Dis 2011; 70 :905–8.