Abstract
The SpAs are a group of overlapping, chronic, inflammatory rheumatic diseases including AS, a chronic inflammatory disease primarily affecting the SI joints. In addition to inflammatory back pain, AS patients are also more likely to experience extra-articular manifestations belonging to the SpA concept which can affect the eyes, the gastrointestinal tract and the skin and other related inflammatory conditions. This review focuses on current progress in treatment options in SpA with special emphasis on extra-articular features. TNF inhibition has demonstrated effectiveness in the treatment of AS symptoms and all currently available anti-TNF agents appear to have similar efficacy. However, the efficacy of anti-TNF agents varies in the treatment of extra-articular manifestations and comorbidities. Analyses of trials of anti-TNF agents in patients with AS have revealed significant reductions in the incidence of flares of uveitis and IBD with infliximab and adalimumab (uveitis only) treatment but not with etanercept. All three anti-TNF agents (infliximab, adalimumab, etanercept) have demonstrated efficacy in psoriasis (not associated with AS). When evaluating as to which agent to use in the treatment of AS, an important consideration is the overall well-being of the patient. This should include any additional inflammatory burden that manifests in other parts of the body, which may currently be subclinical. Based on current evidence, among TNF inhibitors, the monoclonal antibodies (infliximab and adalimumab) are more appropriate than etanercept if extra-articular manifestations or comorbid conditions are present or suspected. To date, infliximab appears to be the best studied agent with a wide spectrum of proven efficacy.
Highlights
SpAs [1] are overlapping, chronic, inflammatory rheumatic diseases that primarily include AS, ReA, arthritis with associated IBD and PsA [2]
After 2 h of incubation in the presence of excess unlabelled infliximab, etanercept or soluble TNF, radiolabelled infliximab did not dissociate from transmembrane TNF. These results indicated that infliximab/TNF complexes are less bioactive than soluble TNF dissociated from etanercept [94]
The relative instability of etanercept/ TNF complexes could, in part, explain the observed relative reduction/absence of efficacy for etanercept in some TNF- related conditions [94]. These data suggest that of the TNF- inhibitors, the monoclonal antibodies may be more favourable in the treatment of extra-articular manifestations associated with AS compared with the receptor fusion protein, etanercept
Summary
SpAs [1] are overlapping, chronic, inflammatory rheumatic diseases that primarily include AS, ReA, arthritis with associated IBD and PsA [2]. An epidemiological study of 847 patients in Belgium who fulfilled the modified New York criteria for AS found that 42% had one or more extra-articular manifestations, including acute anterior uveitis (27%), IBD (10%) and psoriasis (11%) [7]. This illustrates the relatively high frequency of extraarticular manifestations in AS patients. Eye. Acute anterior uveitis (iritis) is a common extra-articular manifestation in AS patients [28]. A retrospective study of patients with SpA further confirms the efficacy of TNF- inhibitors in reducing acute uveitis flares (Fig. 1) [51]. TNF- inhibitors reduced the incidence of uveitis flares from 51.8/100 patient-years prior to anti-TNF
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