New therapies for ankylosing spondylitis: etanercept, thalidomide, and pamidronate

Cause analysis of conversion to biologics in spondyloarthritis patients with poor response to conventional treatment

OBJECTIVE

We sought to investigate the reasons why spondyloarthritis (SpA) patients failed to respond to non-steroidal anti-inflammatory drugs (NSAIDs) and conventional synthetic disease-modifying antirheumatic drugs (cDMARDs) and the influences of different initial cDMARDs on the likelihood of a switch to biologics.

METHODS

SpA patients were divided into a conventional drug maintenance group and a biologics conversion group to determine the causes of conversion to biologics. Then, we divided all patients into three groups according to different initial cDMARDs, NSAID monotherapy, NSAID + (sulfasalazine or thalidomide) double combination, and NSAID + sulfasalazine + thalidomide triple combination therapy groups, to clarify the influence of initial treatment on later conversion to biologics.

RESULTS

This study includes 202 patients, including 97 patients in the conventional drug maintenance group and 105 patients in the biologics conversion group. The mean age of the conventional drug maintenance group was higher than that of the biologics conversion group (40.8 ± 14.3 vs. 33.8 ± 12.3 years, P < 0.05). Uveitis (OR 5.356, P < 0.05) is positively correlated with conversion to biological therapy, while age (OR 0.940, P < 0.05) is negatively correlated. The proportion of NSAID monotherapy, double combination, and triple combination groups converted to biological agents was 80%, 51.1%, and 23.2%, respectively (P < 0.05).

CONCLUSION

Age and uveitis are related to conversion to biologics therapy. The early combination of sulfasalazine and thalidomide with NSAIDs may lower the probability of conversion to biologics therapy in the later stage and offer a new option for patients with limited use of biologics in SpA patients. Key Points • Patients' move to biologics may be caused mostly by inadequate disease control by conventional oral medications. • Regardless of axial vs. peripheral joint involvement, combination drug therapy was superior to single drug therapy in controlling SpA and decreasing the probability of conversion to a biological agent. • For SpA patients who are not candidates for biologics due to contraindications or other reasons, early combination application of NSAIDs, sulfasalazine, and thalidomide may be a new choice.

Thalidomide reduces recurrence of ankylosing spondylitis in patients following discontinuation of etanercept

A previous study showed that most ankylosing spondylitis (AS) patients presented recurrence within 6 months post-discontinuation of etanercept. How to reduce recurrence following discontinuation of etanercept should be further researched. In this study, 111 ankylosing spondylitis patients meeting the Assessment in AS 20 % response (ASAS20) criteria after 12-week administration of etanercept were randomized into three groups: Group I, 150 mg thalidomide once/day; Group II, 1 g sulfasalazine, twice/day; Group III, NSAIDs for the maintenance treatment. The patients were regularly followed up once a month, and AS recurrence was evaluated with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), the patient global assessment (PGA), and rachialgia. The follow-up lasted for 1 year, and AS recurrence was considered as the end of a visit. Finally, 100 patients completed the follow-up study, of whom 30 were in Group I, 33 in Group II, and 37 in Group III. The average follow-up period was 5.1 ± 3.9 months and the longest lasted for 12 months. At the end of the follow-up study, the recurrence rates in Groups I, II, and III were, respectively, 60.0 % (18/30), 84.8 % (28/33), and 89.2 % (33/37). The recurrence rates of Group I were statistically significantly lower than that of Group II and III (P = 0.0265; P = 0.0053), while there was no significant difference between Group II and Group III. In addition, we found that PGA, C-reactive protein (CRP), and spinal inflammation could be regarded as predictive factors for AS recurrence by analysis with the Cox proportional hazard model. This study points to a new way for maintenance therapy of AS following discontinuation of etanercept and reveals several useful indicators for prediction of AS recurrence.

The use of alendronate in the treatment of avascular necrosis of the femoral head

The use of bisphosphonates in the treatment of avascular necrosis of the femoral head is an encouraging but relatively new option with most published data being derived from small trials with limited follow-up. We present a clinicoradiological analysis of 395 hips with avascular necrosis which were treated with oral alendronate for three years with a mean follow-up of four years (1 to 8).

Our results show an improvement in the clinical function, a reduction in the rate of collapse and a decrease in the requirement for total hip replacement, compared with the findings of other studies in which no treatment was given. This improvement is particularly marked if the treatment is begun in the pre-collapse stages of the disease. Even in Ficat stage-III hips some benefit was obtained from treatment with alendronate by at least a delay in the need for total hip replacement.

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.

Spondylarthrite ankylosante et ostéoporose

PURPOSE

Ankylosing Spondylitis (AS) is an inflammatory rheumatism characterized by its disease course with flares leading to progressive ankylosis of the spine related to paravertebral ligamentous and discal structures ossification. AS patients suffer significantly more vertebral fractures than control groups. These fractures could affect cervical spine. They are due to either ankylosis-related flawed spine compliance or AS-induced osteoporosis.

CURRENT KNOWLEDGE AND KEY POINTS

The physiopathology of this osteoporosis is multi-factorial, but essentially linked to AS-related inflammatory phenomenons. It is marked by reduced bone density (at lumbar spine and femoral neck), increased bone turnover (with increased urinary C-telopeptide cross-linked collagen type 1), but without any significant change in phosphocalcic blood parameters. Histological features are depressed bone formation, with either maintained or increased resorption.

FUTURE PROSPECTS

The screening of this osteoporosis is based upon investigating people at risk (progressive inflammatory AS) using dual-energy x-ray absorptiometry and biochemical markers of bone turnover. Treatment is based upon a modulation of both inflammatory phenomenons and bone remodelling using bisphosphonates and anti-TNF alpha.

Use of bisphosphonates to improve the durability of total joint replacements

Total joint arthroplasty is very effective for improving the quality of life of patients with end-stage arthritis. Despite advances in materials, surgical technique, and rehabilitation regimens, joint replacements are still fraught with complications leading to their premature failure. Aseptic loosening and osteolysis are the primary causes of implant failure. Other reasons include early migration of components leading to instability, lack of ingrowth into implant porosities, and bone loss caused by stress shielding. Pharmaceutical agents used for preventing and managing postmenopausal osteoporosis (eg, bisphosphonates) may in the future play an important role in improving the long-term duration of joint arthroplasties. Early findings indicate that bisphosphonates upregulate bone morphogenetic protein-2 production and stimulate new bone formation. Because of their anabolic effect on osteoblasts, bisphosphonates have the potential to enhance bone ingrowth into implant porosities, prevent bone resorption under adverse conditions, and dramatically extend the long-term durability of joint arthroplasties. The long-term effects of bisphosphonate use on the mechanical properties of bone have not been adequately investigated. Along with improvements in implant design and material properties, bisphosphonates and other pharmaceutical agents may, in the near future, be part of the growing armamentarium that provides more durable joint arthroplasties.

Endodontic Implications of Bisphosphonate-Associated Osteonecrosis of the Jaws: A Report of Three Cases

Bisphosphonates are commonly used in medicine to maintain bone density in patients with certain nonneoplastic diseases or cancers. A serious adverse effect of bisphosphonates that has substantial dental significance is osteonecrosis that appears to uniquely affect the mandible and maxilla without occurring in other bones of the skeleton. Patients with bisphosphonate associated osteonecrosis of the jaws may present with pain and exposed necrotic bone. This has substantial clinical implications because surgical procedures (including extractions or endodontic surgical procedures) are contraindicated in the jaws of these patients and the presenting pain may mimic pain of odontogenic origin. This report describes three patients with bisphosphonate associated osteonecrosis and emphasizes the endodontic implications of managing these patients.