Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis

A life-threatening abscess in a patient treated with a tumour necrosis factor-alpha antagonist: a case report

A 25-year-old man with a 3-year history of ankylosing spondylitis presented with a sudden onset of pain in his left thigh. His ankylosing spondylitis had been treated for 2 years with the tumour necrosis factor-alpha (TNF-alpha) antagonist infliximab. The initial diagnosis was a muscular tear, and non-steroidal anti-inflammatory drugs were prescribed. 40 days later, the patient had tender swelling with warmth and light redness on his left thigh. His knee function had decreased markedly. His C-reactive protein level was 320 mg/l and white cell count was 30.4 x10(9)/l, indicating severe infection. Magnetic resonance imaging revealed a loculated fluid collection in the quadriceps musculature measuring 30 cm. Hyperintensity seen on T1-weighted images was suggestive of infection. The infliximab therapy was stopped and repeated debridement and drainage performed, with about 2.5 litres of pus evacuated. Flucloxacillin was administered for 2 weeks. The wound was closed 9 days later. The patient was discharged 20 days after surgery. An alternative immunosuppressive therapy--abatacept--was introduced. At the 18-month follow-up, the patient reported only light discomfort in the thigh during exercise, with a mildly impaired range of knee movement. No infectious complications recurred.

[Patient evaluation of the German version of the ASAS/EULAR recommendations for the management of ankylosing spondylitis]

On the initiative of the ASAS (Assessment of SpondyloArthritis International Society) and EULAR (European League against Rheumatism), evidence-based recommendations for the management of ankylosing spondylitis (AS) were drawn up, with healthcare professionals as the target group for these recommendations. To facilitate patient participation in the decision-making process with regard to their disease, and to further improve the doctor-patient relationship, the ASAS and EULAR are working on a patient-friendly version of the recommendations.In order to establish to what extent the ASAS/EULAR recommendations, as translated by German experts, can be understood by patients, the recommendations for health care professionals, together with an evaluation form, was distributed to 105 delegates of the German society for ankylosing spondylitis (Deutschen Vereinigung Morbus Bechterew, DVMB). Responders were questioned on text comprehension and their level of agreement (0: not agree at all to 10: fully agree). Space was also provided for additional comments.In total, 59 delegates filled out the questionnaire (rate of return: 56.2%). For recommendation Nos. 1, 2, 5, 6 and 7, text comprehension was moderate. On average, the recommendations were positively assessed with 8.38+/-1.9. Recommendation No. 4 (non-pharmacological therapy) was given the highest agreement (9.54+/-1.02), while recommendation No. 7 (corticosteroids, 6.54+/-2.55) received the lowest agreement. The acceptance of the recommendation was high with 87.9% questions answered.For the first time, the German expert translation of recommendations for the management of AS patients was evaluated by patients. The present translation met with broad approval. To minimize text comprehension problems, patients should be involved in compiling a future patient version.

Anti-inflammatory and anti-nociceptive effects of Zeyheria montana (Bignoniaceae) ethanol extract

In this work, the analgesic and anti-inflammatory activities of Zeyheria montana Mart. ethanol leaf extract were investigated at doses of 75, 150 and 300 mg/kg body weight. In the analgesic assay, against a chemical stimulus in mice, acetic acid-induced writhes were significantly inhibited by the extract at doses of 75 mg/kg (67.27%), 150 mg/kg (49.38%) and 300 mg/kg (82.87%). Also, a vigorous decrease in hyperalgesia was observed when measured after 2 h and 6 h of lipopolysaccharide stimulation of rats for all doses of extract tested. Z. montana extract, at doses of 75 and 300 mg/kg, caused very slight central analgesia in rats submitted to thermal stimulus, particularly noticeable at 30 min following treatment. The anti-inflammatory activity of Z. montana extract on carrageenan-induced oedema in rats was evaluated. The oedema development, measured at 180 min following carrageenan intraplantar injection, was significantly reduced by all tested doses: 75 mg/kg (33.30%), 150 mg/kg (45.80%) and 300 mg/kg (75.00%). The LD50 value was greater than 2000 mg/kg. These results demonstrated that the ethanol extract from Z. montana leaf possesses anti-nociceptive and anti-inflammatory activities, which could be of relevance for the pharmacological control of pain and inflammatory processes.

The psoriatic arthritis cost evaluation study: a cost-of-illness study on tumour necrosis factor inhibitors in psoriatic arthritis patients with inadequate response to conventional therapy

OBJECTIVE

To evaluate costs, benefits and cost-effectiveness of anti-TNF agents in PsA patients with inadequate response to conventional treatment.

METHODS

A total of 107 patients, from nine Italian rheumatology centres, with different forms of PsA were given anti-TNF treatment, mainly etanercept (87%). Information on resource use, health-related quality of life, disease activity, function and laboratory values were collected at baseline and through out the 12 months of therapy. Cost (expressed in euro 2007) and utility (measured by EuroQol) before and after anti-TNF therapy initiation were compared in order to estimate the incremental cost per quality-adjusted life year (QALY) gained, and cost-effectiveness acceptability curve was calculated.

RESULTS

At the end of 12 months, there was a significant increase in direct cost due to an increase of drug cost caused by TNF inhibitors that was only partially offset by the decrease in indirect cost. In the last 6 months of therapy, the direct cost increased by euro5052, the cost for the National Health System (NHS) by euro5044 and the social cost by euro4638. However, a gain of 0.12 QALY resulted in a cost per QALY gained of euro40 876 for the NHS and of euro37 591 for the society. The acceptability curve showed that there would be a 97% likelihood that anti-TNF therapy would be considered cost-effective at willingness-to-pay threshold of euro60 000 per QALY gained.

CONCLUSION

Cost-effectiveness ratios are within the commonly accepted willingness-to-pay threshold. These results need to be confirmed in larger samples of patients.

Occupational physical activities and long-term functional and radiographic outcomes in patients with ankylosing spondylitis

OBJECTIVE

We sought to identify specific occupational activities associated with functional limitations and radiographic damage in patients with longstanding ankylosing spondylitis (AS).

METHODS

We asked patients diagnosed with AS for >or=20 years to report all past occupations, which we mapped to specific physical activities using the Occupational Information Network, which is the US Department of Labor job classification database. For each occupation reported, we obtained ratings for 13 physical abilities of the worker and 13 aspects of the work environment or work tasks (work context) thought to be most relevant to patients with AS. Averages for each measure, weighted by the number of years in each job, were related to the degree of functional limitation as assessed by the Bath AS Functional Index (BASFI) and to the extent of spinal radiographic damage as assessed by the Bath AS Radiology Index for the spine (BASRI-s).

RESULTS

Among 397 patients, those with a history of jobs requiring dynamic flexibility (the ability to repeatedly bend, stretch, twist, or reach) had more functional limitations than those whose past jobs required little or no dynamic flexibility (adjusted mean BASFI score 48.3 in the top quartile versus 38.1 in all others). Those whose past jobs required more dynamic flexibility, extent flexibility, and exposure to whole body vibration also had significantly higher BASRI-s scores.

CONCLUSION

Bending, twisting, and stretching are the occupational activities associated with greater functional limitations and radiographic damage in patients with longstanding AS. Exposure to whole body vibration was also associated with more radiographic damage.

Medical management of ankylosing spondylitis

In the following literature review the authors consider the available evidence for the medical management of patients with ankylosing spondylitis (AS), and they critically assess current treatment guidelines. Medical therapy for axial disease in AS emphasizes improvement in patients' pain and overall function. First-line treatments include individualized physical therapy and nonsteroidal antiinflammatory drugs (NSAIDs) in conjunction with gastroprotective therapy. After an adequate trial of therapy with two NSAIDs exceeding 3 months or limited by medication toxicity, the patient may undergo tumor necrosis factor-alpha blockade therapy. Response should occur within 6-12 weeks, and patients must undergo tuberculosis screening. Evidence does not currently support the use of disease modifying antirheumatic drugs, corticosteroids, or radiotherapy in AS.

Evidence-based recommendations for the management of ankylosing spondylitis: systematic literature search of the 3E Initiative in Rheumatology involving a broad panel of experts and practising rheumatologists

OBJECTIVE

Recommendations and/or guidelines represent a popular way of integrating evidence-based medicine into clinical practice. The 3E Initiatives is a multi-national effort to develop recommendations for the management of rheumatic diseases, which involves a large number of experts combined with practising rheumatologists addressing specific questions relevant to clinical practice.

METHODS

Ten countries participated in three rounds of discussions and votes concerning the management of AS. A set of nine questions was formulated in the domains of diagnosis, monitoring and treatment, after a Delphi procedure. A literature search in MedLine was conducted. Predefined outcome parameters for the domains of diagnosis, monitoring and treatment were assessed. The evidence to support each proposition was evaluated and scored. After discussion and votes, the final recommendations were presented using brief statements by each national group, following which the final international recommendations were formulated.

RESULTS

A total of 2699 papers were found and 467 were selected for analysis. Twelve key recommendations were developed: three in the domain of diagnosis addressing general diagnostic considerations, early AS diagnosis and general practitioners' referral recommendations; three concerning monitoring of AS disease activity, severity and prognosis; six concerning pharmacological treatment (except biologics): non-steroidal anti-inflammatory drugs/COX-II inhibitors, bisphosphonates and treatment of enthesitis. The compiled agreement among experts ranged from 72% to 93%.

CONCLUSION

Recommendations for the management of AS were developed using an evidence-based approach followed by expert/physician consensus with high level of agreement. Involvement of a larger and more representative group of rheumatologists may improve their dissemination and implementation in daily clinical practice.

Nonsurgical management of ankylosing spondylitis

Object

The aim of this study was to review the current evidence-based nonsurgical management strategies of ankylosing spondylitis (AS) for spine surgeons. Whereas surgical management is indicated in a highly selected group, nonsurgical management is itself a useful measure for nearly all patients with AS.

Methods

The authors conducted a literature review of PubMed using relevant search words. All the articles published in English in the last 15 years were reviewed and the level of evidence provided by them was noted.

Results

Nonpharmacological treatments in the form of physical therapy and patient education have Level Ib evidence in maintaining function in AS. There is Level Ib evidence supporting the use of nonsteroidal antiinflammatory drugs (NSAIDs) and coxibs for treatment in patients with symptoms. There is not enough evidence to support the use of conventional disease-modifying antirheumatoid arthritis drugs. Tumor necrosis factor (TNF)α inhibitors (infliximab, etanercept, and adalimumab) are associated with Level Ib evidence in improving spinal pain, function, inflammatory biomarkers, and spinal inflammation detected by magnetic resonance imaging in patients in whom symptom duration has exceeded 3 months.

Conclusions

Physical therapy and patient education are useful for all patients diagnosed with AS. If symptomatic, patients are started with either a course of nonselective NSAIDs or a selective cyclooxygenase-2 inhibitor. The role of NSAIDs as a disease-modifying therapy in the treatment of AS is increasingly being understood. The central role of TNF in the pathogenesis of AS is now known, and the advent of biological treatment in the form of anti–TNFα factors has revolutionized the medical management of AS and is used in patients with axial disease whose symptoms persist despite an adequate dose of NSAIDs.

Economic evaluation of etoricoxib versus non-selective NSAIDs in the treatment of ankylosing spondylitis in the UK

OBJECTIVES

To evaluate the cost-effectiveness of etoricoxib, a cyclooxygenase (COX)-2 selective inhibitor, versus non-selective nonsteroidal anti-inflammatory drugs (nsNSAIDs) in the treatment of ankylosing spondylitis (AS).

METHODS

The cost-effectiveness of etoricoxib versus nsNSAIDs was evaluated from the UK National Health Service (NHS) and society perspective with a decision-analytic model. Patients stayed on initial therapy throughout 52 weeks unless they experienced an adverse event (AE) or lacked efficacy, in which case they switched to another nsNSAID or a tumor necrosis factor alpha antagonist. Efficacy data were obtained from a 1-year etoricoxib clinical trial in AS. Bath AS Functional Index (BASFI) data were translated into Quality Adjusted Life Year (QALY) weights using a published data on the relation between BASFI and Short-form (SF) 36 Quality of life scores, as well as the relation between SF-36 and utility. Safety data were based on meta-analyses of etoricoxib trials. Information on treatment pathways, resource consumption, and absenteeism from work was obtained from literature and experts. Model outcomes included QALYs, perforations, ulcers, or bleeds, cardiovascular events, and costs.

RESULTS

Etoricoxib was cost-effective compared to nsNSAIDs in terms of cost per QALY saved ( pound5611). Probabilistic sensitivity analysis found a 77% probability of the incremental cost per QALY saved being within a threshold for cost-effectiveness of pound20 000. The expected direct costs over the 52-week period were pound1.23 (95% uncertainty distribution pound1.10; pound1.39) and pound1.13 per day ( pound0.78; pound1.55) for patients starting with etoricoxib and nsNSAIDs, respectively. When costs related to absenteeism were taken into account, the cost per QALY saved was pound281.

CONCLUSIONS

Given the underlying assumptions and data used, this economic evaluation demonstrated that, compared to nsNSAIDs, etoricoxib is a cost-effective therapy for AS patients in the UK.

Clinical pharmacokinetics and use of infliximab

Tumor necrosis factor-alpha (TNFalpha) is a key proinflammatory cytokine involved in chronic inflammatory diseases. Infliximab, a chimeric (human-murine) monoclonal IgG1 anti-TNFalpha antibody, is used in the treatment of Crohn's disease (including fistulising disease) and rheumatoid arthritis (in combination with methotrexate) if standard treatments have failed. The indications for infliximab have recently been expanded to include ankylosing spondylitis, psoriatic arthritis, psoriasis and ulcerative colitis. The biological agent infliximab is given by multiple intravenous infusions in a dosage of 3-5 mg/kg (initially at weeks 0, 2 and 6; subsequently in intervals of 4-8 weeks). In controlled trials, clinical response rates of 20-40% have been achieved with such regimens in Crohn's disease and rheumatoid arthritis. However, the therapeutic benefits must be balanced against the risks of a variety of severe adverse events (e.g. severe infections including tuberculosis, hepatotoxicity, infusion reactions, serum sickness-like disease and lymphoma). Following single and multiple infusions of infliximab, no relevant differences in median concentration-time profiles have been observed between patients with Crohn's disease, patients with rheumatoid arthritis and patients with psoriasis. The apparent volume of distribution of the high-molecular-weight infliximab (149.1 kDa) is low (3-6L) and represents the intravascular space. The long persistence in this compartment (elimination half-life 7-12 days, mean residence time 12-17 days) is due to the very low systemic clearance of about 11-15 mL/hour (0.18-0.25 mL/minute). Elimination of infliximab is most probably accomplished through degradation by unspecific proteases. During multiple infusions (every 4-8 weeks), no accumulation was observed, and serum concentrations and the area under the plasma concentration-time curve of infliximab increased in proportion to the infused dose, indicating linear pharmacokinetics. Co-medication with methotrexate delayed the decline in the serum concentrations of infliximab. When relating serum concentrations to the clinical response in patients with rheumatoid arthritis and patients with Crohn's disease, it can be assumed that trough concentrations above 1 microg/mL could be used as a kind of therapeutic target. In the future, identification of biomarkers for (non-)response and risk factors for adverse drug reactions would be very helpful. Furthermore, combined biological, pharmacokinetic, pharmacogenomic and clinical studies have not yet been performed and are needed to optimise the therapeutic potential of infliximab, which is currently established as a rescue treatment in refractory patients.

Assessments in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease requiring regular medical care and monitoring to alleviate symptoms, maintain function, identify disease progression and initiate appropriate, timely therapies. Monitoring of the AS patient in clinical daily practice should not only include general history taking and physical examination, but also incorporate specific concepts, pertaining to the disease, which will aid in the detection of disease progression, the requirement of therapeutic intervention and the response to therapy. The Assessments in AS (ASAS) international working group has defined a core set of disease concepts that should be a part of everyday clinical record-keeping in AS, and has identified and validated measurement instruments corresponding to these health concepts, which can easily be incorporated into clinical practice. The group has also developed recommendations for management and a consensus statement for the use of biological therapies in AS, which includes recommendations for the monitoring of AS patients receiving these therapies. This chapter reviews the recommendations for monitoring AS patients in daily clinical practice, with particular regard to those receiving biological treatments.

Tai chi for disease activity and flexibility in patients with ankylosing spondylitis--a controlled clinical trial

We investigated the effects of tai chi on disease activity, flexibility and depression in patients with ankylosing spondylitis (AS). We allocated 40 patients to either a tai chi treatment group or a no-treatment control group. The tai chi group performed 60 min of tai chi twice weekly for eight consecutive weeks and 8 weeks of home-based tai chi, after which the group showed significant improvement in disease activity and flexibility compared to the control group. All outcome measures were significantly lower in the tai chi group than they were during pre-treatment, while they did not change in the control group. These findings suggest that tai chi can improve disease activity and flexibility for patients with AS. Tai chi is an easily accessible therapy for patients and, as such, may be an effective intervention for AS. However, we cannot completely discount the possibility that the placebo effect was responsible for the improvement.

Infliximab in the treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic, progressive disease characterized by inflammation in the spine and sacroiliac joints which causes pain, stiffness and the potential for spinal ankylosis. It is associated with significant functional impairment. It is common and since onset is often in young people, the burden of disease is considerable. Conventional treatment including non-steroidal antiinflammatory drugs (NSAIDs) and physiotherapy have proven but limited efficacy in controlling symptoms and preventing progression of spinal manifestations. Infliximab, a chimeric monoclonal antibody which binds to and inhibits tumor necrosis factor alpha (TNFalpha), is highly effective in controlling disease activity in AS. In AS, infliximab 5 mg/kg body weight is usually given as an infusion at weeks 0, 2 and 6, and then every 6-8 weeks. When infliximab is used in combination with NSAIDs a rapid improvement in disease activity by at least 50% is seen in as many as 50% of AS patients. Infliximab has been shown to have ongoing efficacy for as long as regular infusions continue and is safe in the medium term. Magnetic resonance studies show major reductions in spinal inflammation during treatment with infliximab, however ongoing studies will assess if infliximab has disease modifying effect in AS.

Treatment of ankylosing spondylitis: focus on etanercept

Ankylosing spondylitis is a chronic inflammatory condition which preferentially affects the axial skeleton, often beginning in the sacroiliac joints. The etiology of the pathologic lesions of this condition including enthesitis, erosive articular changes, osteitis, and fibrous ankylosis, as well as changes which occur in the eye, gastrointestinal tract, cardiovascular system, and lungs is unknown; however, there is a strong association with HLA-B27, which indicates altered immunity. One of the major mediators of the immune response is TNF-alpha, which functions as a pleiotrophic soluble messenger primarily from macrophages. TNF-alpha is principally involved with activation of both normal and transformed cells, including endothelium, synoviocytes, osteoclasts, chondrocytes, and fibroblasts. The cornerstone of medical management of ankylosing spondylitis includes intensive physical therapy and nonsteroidal anti-inflammatories for symptomatic relief. However, it is becoming increasingly recognized that TNF-alpha blockade has an important role in the reduction of spine and joint inflammation. This review discusses the data that supports use of etanercept in the treatment of ankylosing spondylitis.

An evidence-based update on nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), including both traditional nonselective NSAIDs and the selective cyclooxygenase (COX)-2 inhibitors, are widely used for their anti-inflammatory and analgesic effects. NSAIDs are a necessary choice in pain management because of the integrated role of the COX pathway in the generation of inflammation and in the biochemical recognition of pain. This group of drugs has recently come under scrutiny because of recent focus in the literature on the various adverse effects that can occur when applying NSAIDs. This review will provide an educational update on the current evidence of the efficacy and adverse effects of NSAIDs. It aims to answer the following questions: (1) are there clinically important differences in the efficacy and safety between the different NSAIDs, (2) if there are differences, which are the ones that are more effective and associated with fewer adverse effects, and (3) which are the effective therapeutic approaches that could reduce the adverse effects of NSAIDs. Finally, an algorithm is proposed which delineates a general decision-making tree to select the most appropriate analgesic for an individual patient based on the evidence reviewed.

Adalimumab in ankylosing spondylitis: an evidence-based review of its place in therapy

INTRODUCTION

Ankylosing spondylitis (AS) is an idiopathic chronic inflammatory disease that has prominent effects on the spine and peripheral joints. In addition, extraarticular manifestations such as enthesitis and acute anterior uveitis may be clinically important. In recent years, the therapy of AS has changed, largely due to the introduction of inhibitors of the proinflammatory cytokine tumor necrosis factor (TNF). Adalimumab, a human monoclonal antibody specifically for TNF, is the most recent of the TNF blocking agents that have been approved for the treatment of active, nonsteroidal antiinflammatory drug (NSAID)-refractory patients with AS.

AIMS

To evaluate the evidence for the therapeutic value of adalimumab in ankylosing spondylitis.

EVIDENCE REVIEW

There is clear evidence that adalimumab, administered 40 mg subcutaneously every 2 weeks, substantially improves the signs and symptoms of NSAID-refractory, active AS when compared with placebo treatment. There is ample evidence that adalimumab causes significant improvements in physical health status and overall AS-specific, health-related quality of life and physical functioning, which consequently leads to better work productivity. There is substantial evidence that adalimumab improves spinal and sacroiliac joint inflammation in AS patients. Initial results from clinical trials suggest that there is no increased risk of serious infections or malignancies in adalimumab-treated patients with AS. The most common adverse events were injection-site reactions. Limited economic evidence suggests that adalimumab 40 mg may be cost effective when used according to current valid treatment guidelines.

PLACE IN THERAPY

Adalimumab is an effective treatment for patients with active AS.

Management of psoriatic arthritis: the therapeutic interface between rheumatology and dermatology

Psoriatic arthritis is an inflammatory arthritis, which occurs in up to 30% of individuals with psoriasis. Dermatologists and other physicians treating psoriasis are in an ideal position to screen for the condition, and with rheumatologists, strategize optimal therapy. Mild skin and joint manifestations may be treated effectively with topical agents, ultraviolet light therapy, and nonsteroidal anti-inflammatory drugs. More severe manifestations of the disease, including progressive peripheral joint damage, spine disease, enthesitis, dactylitis, and severe skin changes, require systemic therapy. Traditional systemic agents include methotrexate, sulfasalazine, and cyclosporine. When these agents are not adequate or not tolerated, new biologic agents, particularly anti-tumor necrosis factor (TNF) compounds, have shown significant and enduring benefit in all disease domains, improvement in quality of life and function, and inhibition of progressive joint damage.

Ankylosing spondylitis and symptom-modifying vs disease-modifying therapy

The main objectives of medical therapy in ankylosing spondylitis (AS) are to relieve pain, stiffness and fatigue and to prevent structural damage. The Assessment in Ankylosing Spondylitis Working Group has proposed different domains with specific instruments to assess the efficacy of therapeutic agents classified as symptom-modifying and disease-controlling antirheumatic drugs. Non-steroidal antiinflammatory drugs (NSAIDs) are still the first-line treatment in the management of AS, and they are effective in controlling symptoms such as pain and stiffness and maintaining mobility in many patients. A recent randomized trial suggested that the progression of radiological damage occurs less on continuous use of celecoxib compared with on-demand use. If such findings were confirmed by other studies, the therapeutic value of NSAIDs in AS may extend beyond symptom control. However, for each individual patient, the expected advantages of treatment with NSAIDs should be weighted against any possible gastrointestinal and cardiovascular disadvantages. Disease-modifying antirheumatic drugs (DMARDs) are widely used for second-line therapy in AS, but the evidence for their efficacy is poor. The term 'DMARD' has been borrowed from rheumatoid arthritis, and none of the DMARDs have been shown to prevent or significantly decrease the rate of progression of structural damage which is required to be qualified as a disease-controlling antirheumatic drug for AS. Sulphasalazine is the most extensively studied DMARD and studies suggest some degree of clinical benefit confined to peripheral joint involvement, but no evidence of benefit in axial disease. Methotrexate, which is the gold standard DMARD in rheumatoid arthritis, does not seem to have a substantial therapeutic effect in AS on axial or peripheral joint involvement. Leflunomide appears to exert little beneficial effect, if any, even on peripheral joint involvement. There is also good evidence that local therapy with corticosteroids is effective and may be used in selected patients. Oral corticosteroids may be somewhat effective in relieving the symptoms of AS, but this has not been formally studied. Small studies have reported favourable results with intravenous methylprednisolone pulse therapy, but the effect is temporary. Pamidronate and thalidomide have been used in some preliminary trials but need further studies to assess their potential role in treating AS patients resistant or intolerant to other forms of treatment. Treatment with tumour necrosis factor blockers is not discussed in this review.

Efficacy and safety of adalimumab in patients with ankylosing spondylitis: results of a multicenter, randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the safety and efficacy of adalimumab, a fully human recombinant IgG1 monoclonal antibody that specifically targets human tumor necrosis factor, in patients with active ankylosing spondylitis (AS).

METHODS

This was a multicenter, randomized (2:1 ratio), double-blind, placebo-controlled study to evaluate a subcutaneous injection of adalimumab, 40 mg every other week, compared with placebo for 24 weeks. The primary efficacy end point was the percentage of patients with a 20% response according to the ASsessment in Ankylosing Spondylitis International Working Group criteria for improvement (ASAS20) at week 12. Secondary outcome measures included the ASAS20 at week 24 and multiple measures of disease activity, spinal mobility, and function, as well as ASAS partial remission.

RESULTS

At week 12, 58.2% of adalimumab-treated patients (121 of 208) achieved an ASAS20 response, compared with 20.6% of placebo-treated patients (22 of 107) (P < 0.001). More patients in the adalimumab group (45.2% [94 of 208]) than in the placebo group (15.9% [17 of 107]) had at least a 50% improvement in the Bath Ankylosing Spondylitis Disease Activity Index at week 12 (P < 0.001). Significant improvements in the ASAS40 response and the response according to the ASAS5/6 criteria at weeks 12 and 24 were also demonstrated (P < 0.001). Partial remission was achieved by more adalimumab-treated patients than placebo-treated patients (22.1% versus 5.6%; P < 0.001). Adalimumab-treated patients reported more adverse events (75.0% versus 59.8% of placebo-treated patients; P < 0.05), but there was no statistically significant difference in the incidence of infections. Most adverse events were mild or moderate in severity.

CONCLUSION

Adalimumab was well-tolerated during the 24-week study period and was associated with a significant and sustained reduction in the signs and symptoms of active AS.

Developments and current pharmacotherapeutic recommendations for ankylosing spondylitis

The introduction of anti-TNFalpha therapy into the field of rheumatology has led to dramatic improvements in patient care, perhaps the most remarkable being in the management of ankylosing spondylitis. As experience with these compounds grows, their place in therapeutic strategy is becoming clearer, and it has been possible to develop evidence- and expertise-based recommendations for the management of ankylosing spondylitis to aid the clinician in patient care. This review outlines treatment advances in ankylosing spondylitis, including the use of anti-TNFalpha agents, and how these have been incorporated into clinical recommendations for daily use.

The role of nonsteroidal anti-inflammatory medications and exercise in the treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic systemic rheumatic disease that primarily affects the sacroiliac joints and spine. Even with the development of tumor necrosis factor-alpha inhibitors, which have revolutionized the treatment of this disease, the combination of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and a life-long exercise program still form the first step in its management. Multiple clinical trials have addressed the efficacy and safety of both nonselective and selective NSAIDs. Gastrointestinal toxicity remains their major side effect, with increased concern about the potential of cardiovascular toxicity, especially with the selective cyclooxygenase-2 inhibitors. A specific set of recommendations has been proposed for the management of AS.

ASAS/EULAR recommendations for the management of ankylosing spondylitis

OBJECTIVE

To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the 'ASsessment in AS' international working group and the European League Against Rheumatism.

METHODS

Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise.

RESULTS

The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I-IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion.

CONCLUSION

Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.