Long-term efficacy and safety of etanercept after readministration in patients with active ankylosing spondylitis

Inflammatory Bowel Disease as a Paradoxical Reaction to Anti-TNF-α Treatment-A Review

TNF-α inhibitors (TNFis) have revolutionized the treatment of certain chronic immune-mediated diseases, being widely and successfully used in rheumatic inflammatory diseases, and have also proved their efficacy in the treatment of inflammatory bowel disease (IBD). However, among the side effects of these agents are the so-called paradoxical effects. They can be defined as the appearance or exacerbation of a pathological condition that usually responds to this class of drug while treating a patient for another condition. A wide range of paradoxical effects have been reported including dermatological, intestinal and ophthalmic conditions. The causal mechanism of occurrence may implicate an imbalance of cytokines, but is still not fully understood, and remains a matter of debate. These paradoxical reactions often show improvement on discontinuation of the medication or on switching to another TNFi, but in some cases it is a class effect that could lead to the withdrawal of all anti-TNF agents. Close monitoring of patients treated with TNFis is necessary in order to detect paradoxical reactions. In this study we focus on reviewing IBD occurrence as a paradoxical effect of TNFi therapy in patients with rheumatological diseases (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and juvenile idiopathic arthritis).

Defining and managing flares in axial spondyloarthritis

PURPOSE OF REVIEW

Flares correspond to fluctuations in disease activity or symptoms. They should be avoided in chronic inflammatory diseases. In axial spondyloarthritis (axSpA), work is ongoing to better conceptualise and treat flares. This review highlights recent data on the definition and management of flares in axSpA.

RECENT FINDINGS

Many definitions of flares have been used in clinical trials, limiting the interpretation and comparison of studies. The expert group Assessment of SpondyloArthritis International Society (ASAS) developed a data-driven definition of flares/disease worsening: an increase in Ankylosing Spondylitis Disease Activity Score-C-reactive protein (ASDAS-CRP) of at least 0.9 points, for use in axSpA clinical trials. Flares are more challenging to define in clinical practice because of their multifaceted nature. Qualitative studies have shown that flares from the patient's perspective are related not only to disease activity, but also to fatigue, mood, sleep and general well-being. The management of axSpA relies on a treat-to-target (T2T) strategy and aims at reaching clinical remission while monitoring closely disease activity to prevent and shorten flares.

SUMMARY

The concept of flares has been clarified, and definitions have been developed for use in trials. The T2T approach aims at minimising flares in axSpA. The early recognition of flares and their severity may lead to better management.

Disease modification in ankylosing spondylitis with TNF inhibitors: spotlight on early phase clinical trials

INTRODUCTION

Ankylosing spondylitis (AS) is a chronic inflammatory disease whose main hallmark is involvement of the axial skeleton. Non-steroidal anti-inflammatory drugs (NSAIDs) are the first line treatment; however, their use is limited because of side effects. Tumor necrosis factor inhibitors (TNFi) are a safe and effective therapy, and they have been approved for the management of AS.

AREAS COVERED

This is a review of the efficacy of TNFi in disease modification in AS. It is focused on results from early-phase clinical trials; however, it also discusses the most relevant findings in order to optimize anti-TNF treatment. A literature search was done using PubMed, Medline, Embase, Google Scholar, and Cochrane library, looking for scientific publications from inception to August 2021. Further information was retrieved from ClinicalTrial.gov and Clinicaltrialsregister.eu.

EXPERT OPINION

TNFi have demonstrated short- and long-term improvements in all aspects of disease activity, as well as physical function in patients with AS. They have drastically revolutionized the management of the disease; and even though new drugs have become available in the market, TNFi has not been displaced for the treatment of AS, and still constitute the best alternative when NSAIDs are no-longer an option.

Disease activity in women with ankylosing spondylitis remains higher under Tumour Necrosis Factor inhibitor treatment than in men: a five-year observational study

OBJECTIVE

To assess sex differences in response, level of disease activity, and drug survival in tumour necrosis factor inhibitor (TNFi)-naïve ankylosing spondylitis (AS) patients.

METHOD

Consecutive AS patients, fulfilling the modified New York criteria, were included in a prospective cohort study at initiation of the first TNFi and followed until this medication was stopped (drug survival). Disease activity scores [AS Disease Activity Score using C-reactive protein (ASDAS-CRP), Bath AS Disease Activity Index (BASDAI), and CRP] were measured at 3, 6, and 12 months, and every subsequent year, up to 5 years. The response was defined by the ASDAS-CRP response criteria (clinically important improvement: ASDAS-CRP decrease ≥ 1.1). Analyses included regression methods for repeated measurements and survival analyses.

RESULTS

Overall, 356 patients were included (34% women, mean ± sd age 46 ± 12 years), with a median disease duration of 12 (interquartile range 6;20) years. Women were less likely than men to achieve a clinically important response after 6 months of TNFi treatment (47% vs 64%; relative risk 1.4, 95% confidence interval (CI) 1.1;1.9, p = 0.02], despite a lack of sex differences in mean ASDAS-CRP levels over 5 year follow-up. Adjusted models for BASDAI over 5 years showed that women had a 0.6 point higher BASDAI score than men (β = 0.6 0.1;1.1 <0.02). Numerically, more women than men discontinued treatment over a period of 5 years (hazard ratio = 1.5, 95% CI 0.9;2.5, p = 0.15).

CONCLUSION

Female AS patients show a lower response to TNFi and a higher disease activity compared to men.

Withdrawing Ixekizumab in Patients With Psoriatic Arthritis Who Achieved Minimal Disease Activity: Results From a Randomized, Double-Blind Withdrawal Study

Objective

To evaluate the effect of withdrawing ixekizumab in patients with psoriatic arthritis (PsA) in whom minimal disease activity (MDA) has been achieved after open‐label ixekizumab treatment.

Methods

SPIRIT‐P3 was a multicenter, randomized, double‐blind withdrawal study of biologic treatment–naive adult patients with PsA who were treated with open‐label ixekizumab for 36 weeks (160 mg at week 0, then 80 mg every 2 weeks). Patients in whom MDA was sustained for >3 consecutive months were randomized 1:1, between weeks 36 and 64, to undergo blinded withdrawal of ixekizumab treatment (placebo) or to continue ixekizumab treatment every 2 weeks up to week 104. The primary efficacy end point was time to relapse (loss of MDA) for randomized patients. Patients who experienced a relapse were re‐treated with ixekizumab every 2 weeks up to week 104.

Results

A total of 394 patients were enrolled and received open‐label ixekizumab every 2 weeks. Of those patients, 158 (40%) achieved sustained MDA and were randomized to undergo withdrawal of ixekizumab treatment (placebo every 2 weeks; n = 79) or to continue ixekizumab treatment every 2 weeks (n = 79). Disease relapse occurred more rapidly with treatment withdrawal (median 22.3 weeks [95% confidence interval (95% CI) 16.1–28.3]) compared to those who continued treatment with ixekizumab (median not estimable; P < 0.0001). Sixty‐seven patients (85%) compared to 30 patients (38%) experienced relapse in the placebo group and the continued treatment group, respectively. Median time to achieving MDA again with re‐treatment was 4.1 weeks (95% CI 4.1–4.3); in 64 of 67 patients (96%) who experienced relapse with treatment withdrawal, MDA was achieved again with re‐treatment. Safety was consistent with the known safety profile for ixekizumab.

Conclusion

Continued ixekizumab therapy is superior to ixekizumab withdrawal in maintaining low disease activity in biologic treatment–naive patients with PsA. Re‐treatment with ixekizumab following a relapse may restore disease control in cases of treatment interruption.

Occurrence of anterior uveitis in patients with spondyloarthritis treated with tumor necrosis factor inhibitors: comparing the soluble receptor to monoclonal antibodies in a large observational cohort

Background

The objective of this study was to compare in real life the occurrence of anterior uveitis in patients with spondyloarthritis (SpA), including psoriatic arthritis (PsA), treated with the soluble-receptor etanercept (ETA) or monoclonal antibodies (mAbs).

Methods

This was an observational, retrolective study. Patients with SpA who were prescribed anti-TNF agents between 2000 and 2014 were included. The risk of uveitis was interpreted qualitatively (number of subjects with at least one uveitis) and quantitatively (number of uveitis flares for each individual). Models were adjusted for propensity score of receiving preferentially mAbs or ETA.

Results

Four hundred twenty-nine patients were included (302 with SpA and 127 with PsA); 203 received a mAb and 226 ETA as a first TNF-α inhibitor. Probability of uveitis occurring during the first year of treatment was lower with ETA than with mAbs but not significantly (odds ratio 0.94 [95% confidence interval 0.35; 2.54], p = 0.90, on qualitative analysis and relative risk 0.62 [0.26; 1.46], p = 0.27, on quantitative analysis) after adjustment for the propensity score. The over-time risk of uveitis was numerically higher with ETA than with mAbs, but the differences were not statistically significant.

Conclusion

In this observational study, the risk of uveitis in patients with SpA does not appear to be greater with ETA than with mAb treatment. The occurrence of uveitis in patients receiving an anti-TNF-α agent seems linked more to the history of uveitis than the prescribed molecule.

The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis - 2019

Spondyloarthritis is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular manifestations. The classification axial spondyloarthritis is adopted when the spine and/or the sacroiliac joints are predominantly involved. This version of recommendations replaces the previous guidelines published in May 2013.A systematic literature review was performed, and two hundred thirty-seven studies were selected and used to formulate 29 recommendations answering 15 clinical questions, which were divided into four sections: diagnosis, non-pharmacological therapy, conventional drug therapy and biological therapy. For each recommendation the level of evidence supporting (highest available), the strength grade according to Oxford, and the degree of expert agreement (inter-rater reliability) is informed.These guidelines bring evidence-based information on clinical management of axial SpA patients, including, diagnosis, treatment, and prognosis.

Biological treatment of ankylosing spondylitis: a nationwide study of treatment trajectories on a patient level in clinical practice

BACKGROUND

There is substantial evidence that patients with ankylosing spondylitis (AS) have high response rates to tumour necrosis factor inhibitors (TNFi), a low likelihood of successful treatment termination, but yet a limited drug retention. Whereas several reports have assessed drug retention rates for TNFi in AS, there are few, if any, studies investigating the actual treatment trajectories on a patient level, including subsequent therapy changes and dose reductions, of individual patients. The aim of this study was to describe 5-year treatment trajectories in patients with ankylosing spondylitis (AS) starting a first TNFi.

METHODS

Bio-naïve patients with AS starting a TNFi in 2006-2015 were identified in the nationwide Swedish Rheumatology Quality register and followed until 31 December 2015. All changes in their anti-rheumatic treatment during follow-up were recorded. To further increase precision, these data were complimented by information on the amount of prescribed subcutaneous TNFi collected from pharmacies during each year, retrieved from the Swedish Prescribed Drug Register.

RESULTS

Two thousand five hundred ninety patients started a first TNFi 2006-2015, and after 1 year, 74% remained on their first TNFi. However, after 5 years, this figure was only 46%, although at that time 63% were still on treatment with any biologic, while 30% had no anti-rheumatic treatment at all. After discontinuing the first TNFi, 46% switched directly to a second TNFi, but the drug retention for the second and third TNFi grew successively shorter compared to that for the first TNFi. In contrast, patients remaining on treatment with their first subcutaneous TNFi gradually reduced the dose, so that during the fifth year of treatment only 66% had collected ≥ 75% of the defined daily doses for that year.

CONCLUSION

Less than half of patients with AS will remain on their first TNFi after 5 years, but most are still on a biologic. While patients remaining on treatment with their first TNFi appear to be able to reduce the dose over time, a large proportion cycle through several biologics, and 1/3 have no anti-rheumatic treatment after 5 years. This indicates the importance of thorough follow-up programs as well as a need for alternative therapeutic options.

Withdrawal of infliximab therapy in ankylosing spondylitis in persistent clinical remission, results from the REMINEA study

Background

Recent data suggest that anti-TNF doses can be reduced in ankylosing spondylitis (AS) patients. Some authors even propose withdrawing treatment in patients in clinical remission; however, at present there is no evidence to support this.

Objective

To assess how long AS patients with persistent clinical remission remained free of flares after anti-TNF withdrawal and to evaluate the effects of treatment reintroduction. We also analyze the characteristics of patients who did not present clinical relapse.

Methods

Multicenter, prospective, observational study of a cohort of patients with active AS who had received infliximab as a first anti-TNF treatment and who presented persistent remission (more than 6 months). We recorded at baseline and every 6–8 weeks over the 12-month period the age, gender, disease duration, peripheral arthritis or enthesitis, HLA-B27 status, BASDAI, CRP, ESR, BASFI, and three visual analogue scales, spine global pain, spinal night time pain, and patient’s global assessment.

Results

Thirty-six out of 107 patients (34%) presented persistent remission and were included in our study. After treatment withdrawal, 21 of these 36 patients (58%) presented clinical relapse during follow-up. Infliximab therapy was reintroduced and only 52% achieved clinical remission, as they had before the discontinuation of infliximab; in an additional 10%, reintroduction of infliximab was ineffective, obliging us to change the anti-TNF therapy. No clinical or biological factors were associated with the occurrence of relapse during the follow-up.

Conclusions

Two thirds of patients in clinical remission presented clinical relapse shortly after infliximab withdrawal. Although the reintroduction of infliximab treatment was safe, half of the patients did not present the same clinical response that they had achieved prior to treatment withdrawal.

Non-inferiority of dose reduction versus standard dosing of TNF-inhibitors in axial spondyloarthritis

Objective

The objective was to determine if dose reduction is non-inferior to full-dose TNFi to maintain low disease activity (LDA) in patients already in remission with TNFi, in axial spondyloarthritis.

Methods

Randomized, parallel, non-inferiority, open-label multicentre clinical trial. Patients were eligible if they had axial spondyloarthritis and had been in clinical remission for ≥ 6 months with any available TNFi (adalimumab, etanercept, infliximab, golimumab) at the dose recommended by product labelling. Patients were randomized by automated central allocation to continue the same TNFi dose schedule, or to reduce the dose by roughly half according to the protocol. The main outcome was the proportion of subjects with LDA after 1 year. Serious adverse reactions or infections were recorded.

Results

The trial stopped due to end of the funding period, after 126 patients were randomized; 113 patients (84.1% male, mean age (SD) 45.6 (13.0) years) were included in the main per-protocol subset. Non-inferiority was concluded for LDA at 1 year (47/55 (83.8%) patients in the full-dose and 48/58 (81.3%) patients in the reduced-dose arm, adjusted difference (95% CI) − 2.5% (− 16.6% to 11.7%)). Serious adverse reactions or infections were reported in 7/62 patients (11.3%) assigned to full dose and 2/61 patients (3.3%) assigned to reduced dose (p value = 0.164).

Conclusion

In patients with ankylosing spondylitis in clinical remission for at least 6 months, dose reduction is non-inferior to full TNF inhibitor doses to maintain LDA after 1 year. Serious adverse events may be less frequent with reduced doses.

Trial registration

EU Clinical Trials Registry, EudraCT 2011–005871-18 and ClinicalTrials.gov, NCT01604629.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1772-z) contains supplementary material, which is available to authorized users.

Efficacy and safety of continuing versus withdrawing adalimumab therapy in maintaining remission in patients with non-radiographic axial spondyloarthritis (ABILITY-3): a multicentre, randomised, double-blind study

BACKGROUND

Success of treatment withdrawal in patients with non-radiographic axial spondyloarthritis who are in remission remains unknown. The ABILITY-3 study explored the ability to withdraw adalimumab treatment in patients with non-radiographic axial spondyloarthritis who achieved sustained clinical remission after open-label treatment with adalimumab.

METHODS

ABILITY-3 was a multicentre, two-period study done in 107 sites in 20 countries. We enrolled adult patients (≥18 years) diagnosed with non-radiographic axial spondyloarthritis, fulfilling Assessment of SpondyloArthritis international Society classification criteria but not the modified New York radiologic criterion, who had objective evidence of active inflammation, active disease, and inadequate response to at least two non-steroidal anti-inflammatory drugs. Patients who achieved Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease (<1·3) with open-label adalimumab (40 mg subcutaneously every other week for 28 weeks) at weeks 16, 20, 24, and 28 were randomly assigned (1:1) using an interactive voice or web response system to 40-week, double-blind treatment with adalimumab (continuation) or placebo (withdrawal). The primary efficacy endpoint was the proportion of patients who did not experience a flare (defined as ASDAS ≥2·1 at two consecutive visits) during the double-blind period. Patients who flared were rescued with open-label adalimumab. This study is registered with ClinicalTrials.gov, number NCT01808118.

FINDINGS

Between June 27, 2013, and October 22, 2015, 673 patients were enrolled to the study. The trial completed on April 14, 2017. Of 673 enrolled patients, 305 (45%) achieved sustained remission and were randomly assigned to double-blind treatment (152 patients to adalimumab and 153 to placebo). A greater proportion of patients continuing adalimumab than those receiving placebo did not experience a flare (107 [70%] of 152 patients vs 72 [47%] of 153 patients; p<0·0001) up to and including week 68. Among 673 patients receiving adalimumab at any time, 516 (77%) patients reported an adverse event and 28 (4%) experienced a serious adverse event. The most common adverse events in both the adalimumab and placebo groups were nasopharyngitis (25 [16%] vs 20 [13%]), upper respiratory tract infection (20 [13%] vs 12 [8%]), and worsening of axial spondyloarthritis (ten [7%] vs 21 [14%]).

INTERPRETATION

In patients with active non-radiographic axial spondyloarthritis who achieved sustained remission with adalimumab, continued therapy was associated with significantly fewer patients flaring than was treatment withdrawal.

FUNDING

AbbVie.

Factors Associated With Initiation of Biologics in Patients With Axial Spondyloarthritis in an Urban Asian City: A PRESPOND Study

OBJECTIVE

The aim of this study was to examine if patients' sociodemographic, clinical characteristics, and patient-reported outcomes were associated with biologics initiation in patients with axial spondyloarthritis in Singapore.

METHODS

Data from a dedicated registry from a tertiary referral center in Singapore from January 2011 to July 2016 were used. Initiation of first biologics was the main outcome of interest. Logistic regression analyses were used to explore the association of various factors on biologics initiation.

RESULTS

Of 189 eligible patients (aged 37.7 ± 13.3 years; 76.2% were males), 30 (15.9 %) were started on biologics during follow-up. In the multivariable analysis model, age (odds ratio [OR]; 0.93; 95% confidence interval [CI], 0.89-0.98; p < 0.01), mental component summary score of Short-Form 36 Health Survey (OR, 0.18; 95% CI, 0.03-0.89; p = 0.04), erythrocyte sedimentation rate (OR, 1.02; 95% CI, 1.00-1.04; p = 0.02), presence of peptic ulcer disease (OR, 10.4; 95% CI, 2.21-48.8; p < 0.01), and lack of good response to nonsteroidal anti-inflammatory drugs (OR, 4.44; 95% CI, 1.63-12.1; p < 0.01) were found to be associated with biologics initiation.

CONCLUSIONS

Age, erythrocyte sedimentation rate, mental component summary score, comorbidities of peptic ulcer disease, and responsiveness to nonsteroidal anti-inflammatory drugs were associated with biologics initiation. It is essential that clinicians recognize these factors in order to optimize therapy.

Unique transcriptome signatures and GM-CSF expression in lymphocytes from patients with spondyloarthritis

Spondyloarthritis encompasses a group of common inflammatory diseases thought to be driven by IL-17A-secreting type-17 lymphocytes. Here we show increased numbers of GM-CSF-producing CD4 and CD8 lymphocytes in the blood and joints of patients with spondyloarthritis, and increased numbers of IL-17A⁺GM-CSF⁺ double-producing CD4, CD8, γδ and NK cells. GM-CSF production in CD4 T cells occurs both independently and in combination with classical Th1 and Th17 cytokines. Type 3 innate lymphoid cells producing predominantly GM-CSF are expanded in synovial tissues from patients with spondyloarthritis. GM-CSF⁺CD4⁺ cells, isolated using a triple cytokine capture approach, have a specific transcriptional signature. Both GM-CSF⁺ and IL-17A⁺GM-CSF⁺ double-producing CD4 T cells express increased levels of GPR65, a proton-sensing receptor associated with spondyloarthritis in genome-wide association studies and pathogenicity in murine inflammatory disease models. Silencing GPR65 in primary CD4 T cells reduces GM-CSF production. GM-CSF and GPR65 may thus serve as targets for therapeutic intervention of spondyloarthritis.

Spondyloarthritis is an inflammatory disease with Th17 cells implicated in the pathogenesis. Here the authors show that patients with spondyloarthritis have increased numbers of GM-CSF-secreting blood and synovial lymphocytes, Th17 or not, that carry a unique transcriptional profile including enhanced GPR65 expression.

REDOSER project: optimising biological therapy dose for rheumatoid arthritis and spondyloarthritis patients

Background

Reducing the dose of biological therapy (BT) when patients with immune-mediated arthritis achieve a sustained therapeutic goal may help to decrease costs for national health services and reduce the risk of serious infection. However, there is little information about whether such a decision can be applied universally. Therefore, the objective of this study was to develop appropriateness criteria for reducing the dose of BT in patients with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), and peripheral spondyloarthritis (pSpA).

Methods

The RAND/UCLA appropriateness method was coordinated by experts in the methodology. Five rheumatologists with clinical research experience in RA and/or SpA selected and precisely defined the variables considered relevant when deciding to reduce the dose of BT in the 3 diseases, in order to define patient profiles. Ten rheumatologists with experience in prescribing BT anonymously rated each profile on a scale of 1 (completely inappropriate) to 9 (completely appropriate) after revising a summary of the evidence obtained from 4 systematic literature reviews carried out specifically for this project.

Findings

A total of 2,304 different profiles were obtained for RA, 768 for axSpA, and 3,072 for pSpA. Only 327 (14.2%) patient profiles in RA, 80 (10.4%) in axSpA, and 154 (5%) in pSpA were considered appropriate for reducing the dose of BT. By contrast, 749 (32.5%) patient profiles in RA, 270 (35.3%) in axSpA, and 1,243 (40.5%) in pSpA were considered inappropriate. The remaining profiles were considered uncertain.

Interpretation

Appropriateness criteria for reducing the dose of BT were developed in 3 inflammatory conditions. These criteria can help clinicians treating these disorders to optimize the BT dose. However, further research is needed, since more than 50% of the profiles were considered uncertain and the real prevalence of each profile in daily clinical practice remains unknown.

Possible predictors for relapse from etanercept discontinuation in ankylosing spondylitis patients in remission: a three years' following-up study

The aim of this study is to assess the recurrence probability and the possible predictors in patients with ankylosing spondylitis from etanercept discontinuation in a 3-year observational cohort ( ClinicalTrials.gov : NCT02915354). A cohort of 35 patients who achieved an ASAS 20 response at the end of a randomized controlled trial underwent a 3-year follow-up evaluation. The primary end point was clinical relapse defined as the BASDAI score going back to 80% of its initial level at the beginning of the trial. Prognostic factors of relapse were analyzed using the Cox regression. Median duration of clinical remission was 15.0 months (interquartile range, 3.7-26.3 months). The cumulative probabilities of relapse at 1, 2, and 3 years were 45.7, 57.1, and 60.0%, respectively. The proportion of recurrence was not significantly different between placebo group and etanercept group by Kaplan-Meier analysis (placebo vs. etanercept: 61.11 vs. 58.82%, P = 0.890). Two independent factors associated with increasing risk of relapse were (1) age of patients (25 years or older with risk of 3.07, 95% confidence interval, 1.19-7.97, P = 0.021); (2) onset age (younger than 24 years with risk of 3.12, 95% confidence interval, 1.24-7.83, P = 0.016). No correlation was observed in the present study between the time of relapse and the duration of the treatment with etanercept in AS patients who achieved the ASAS 20 response after receiving the treatment. The older age and younger onset age of patients seems to be important factors associate with an increasing risk of relapse.

DOSAGE AND DURATION OF ETANERCEPT THERAPY FOR ANKYLOSING SPONDYLITIS: A META-ANALYSIS

Objectives: We conducted a meta-analysis of recently published randomized controlled trials (RCTs) to identify the most effective and safe etanercept dosing regimen and duration of therapy for the treatment of patients with ankylosing spondylitis (AS).

Methods: We systematically reviewed PubMed, Embase, Cochrane Library, and Web of Science databases for RCTs. The proportion of patients attaining 20 percent improvement (according to the Spondyloarthritis International Society response criteria [ASAS 20]) was evaluated as a primary outcome. Secondary outcomes included 50 percent increase in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI 50) used for evaluating efficacy, as well as the BASDAI/Bath Ankylosing Spondylitis Functional Index (BASFI) scores and adverse events.

Results: ASAS 20 indicated that the efficacy of etanercept did not differ amongst dosing regimens (25 mg twice-weekly versus 50 mg once-weekly: relative risk [RR], 2.18, 95 percent confidence interval [CI], 1.78–2.67 versus RR, 2.00, 95 percent CI, 1.70–2.37). The ASAS 20 reported subgroup differences among treatment durations of less than 12 weeks (RR, 2.70; 95 percent CI, 2.09–3.49); 12 weeks (RR, 1.74; 95 percent CI, 1.37–2.22); and more than 12 weeks (RR, 2.56; 95 percent CI, 1.88–3.48). Other outcomes included BASDAI, BASDAI 50, and BASFI. Drug safety differed according to the treatment regimen and duration.

Conclusion: Our meta-analysis found that there was no significant efficacy difference between 50 mg once-weekly and 25 mg twice-weekly dosing for the treatment of AS, and a dosing duration of less than 12 weeks was more effective for treating AS patients.

Long-term safety and efficacy of infliximab for the treatment of ankylosing spondylitis

The introduction of TNFα blockers has revolutionized the treatment of ankylosing spondylitis (AS). The objectives of this review are to summarize the most up-to-date data on long-term efficacy and safety of infliximab in AS, with special emphasis on axial and extra-articular disease, predictors of response, and radiological response. The general consensus of this literature search was that infliximab is highly efficacious in the treatment of AS. Most studies have demonstrated good clinical outcomes after 3 years of treatment, as measured by Spondyloarthritis International Society response in 75%-85% of treated AS patients. Reports on the long-term effects of infliximab as documented by radiological findings, however, are controversial. While some studies reported a similar progression rate as that of the historical OASIS cohort, others have suggested that infliximab may halt new bone formation. The long-term safety of infliximab is well known, mainly from data stored in national registries. While it has been suggested that side effects of infliximab may be fewer in AS compared to rheumatoid arthritis, data on this issue are sparse, with most of the information on long-term safety pertaining to rheumatoid arthritis. It can however be concluded that the long-term efficacy of infliximab is apparently maintained in AS and with an acceptable safety profile.

Evaluation of dose reduction versus standard dosing for maintenance of remission in patients with spondyloarthritis and clinical remission with anti-TNF (REDES-TNF): study protocol for a randomized controlled trial

BACKGROUND

Dose reduction schedules of tumor necrosis factor antagonists (anti-TNF) as maintenance therapy in patients with spondyloarthritis are used empirically in clinical practice, despite the lack of clinical trials providing evidence for this practice.

METHODS/DESIGN

To address this issue the Spanish Society of Rheumatology (SER) and Spanish Society of Clinical Pharmacology (SEFC) designed a 3-year multicenter, randomized, open-label, controlled clinical trial (2 years for inclusion and 1 year of follow-up). The study is expected to include 190 patients with axial spondyloarthritis on stable maintenance treatment (≥4 months) with any anti-TNF agent at doses recommended in the summary of product characteristics. Patients will be randomized to either a dose reduction arm or maintenance of the dosing regimen as per the official labelling recommendations. Randomization will be stratified according to the anti-TNF agent received before study inclusion. Patient follow-up, visit schedule, and examinations will be maintained as per normal clinical practice recommendations according to SER guidelines. The study aims to test the hypothesis of noninferiority of the dose reduction strategy compared with standard treatment. The first patients were recruited in July 2012, and study completion is scheduled for the end of April 2015.

DISCUSSION

The REDES-TNF study is a pragmatic clinical trial that aims to provide evidence to support a medical decision now made empirically. The study results may help inform clinical decisions relevant to both patients and healthcare decision makers.

TRIAL REGISTRATION

EudraCT 2011-005871-18 (21 December 2011).

Consensus Document on Prevention and Treatment of Tuberculosis in Patients for Biological Treatment

Tuberculosis risk is increased in patients with chronic inflammatory diseases receiving any immunosuppressive treatment, notably tumor necrosis factor (TNF) antagonists therapy. Screening for the presence of latent infection with Mycobacterium tuberculosis and targeted preventive treatment to reduce the risk of progression to TB is mandatory in these patients. This Consensus Document summarizes the current knowledge and expert opinion of biologic therapies including TNF-blocking treatments. It provides recommendations for the use of interferon-gamma release assays (IGRA) and tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection in these patients, and for the type and duration of preventive therapy.

Long-term outcome of patients with active ankylosing spondylitis with etanercept-sustained efficacy and safety after seven years

INTRODUCTION

Data from clinical studies on the long-term efficacy and safety of anti-tumor necrosis factor (TNF)-α therapy in patients with ankylosing spondylitis (AS) are scarce. This is the first report on continuous treatment with the TNFα fusion protein etanercept over seven years (y).

METHODS

Overall, 26 patients with active AS were initially treated with etanercept 2 × 25 mg s.c./week with no concomitant disease modifying anti-rheumatic drugs (DMARDs) or steroids. The clinical response was assessed by standardized parameters. The primary outcome was the proportion of patients in the Spondyloarthritis International Society (ASAS) partial remission at seven years. AS disease activity scores (ASDAS) for status and improvement were compared to conventional outcome measures.

RESULTS

Overall, 21/26 patients (81%) completed two years of treatment and 16/26 patients (62%) completed seven years. In the completer analysis, 31% patients were in ASAS partial remission at seven years, while 44% patients showed an ASDAS inactive disease status. Mean Bath AS activity index (BASDAI) scores, which were elevated at baseline (6.3 ± 0.9), showed constant improvement and remained low: 3.1 ± 2.5 at two years and 2.5 ± 2.2 at seven years, while ASDAS also improved (3.9 ± 0.7 at baseline, 1.8 ± 0.9 at two years, 1.6 ± 0.8 at seven years), all P <0.001. From the 10 dropouts, only 5 patients discontinued treatment due to adverse events. Patients who completed the study had lower baseline Bath AS function index (BASFI) scores vs. patients who discontinued. No other clinical parameter at baseline could predict any long-term outcome.

CONCLUSIONS

This study confirms the clinical efficacy and safety of etanercept in patients with active AS over seven years of continuous treatment. After seven years, more than half of the initially treated patients remained on anti-TNF therapy, and one-third were in partial remission.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01289743

Health-related quality of life in patients with ankylosing spondylitis: a comprehensive review

Ankylosing spondylitis (AS) is a complex systemic rheumatological disease which often causes severe disability and impaired quality of life (QoL). We searched the PubMed/MEDLINE electronic database for available literature on QoL and its predictors in patients with AS. Recent evidence indicates that AS patients have poorer QoL compared to the general population, but similar to that of patients with other rheumatological disorders. Disease activity is one of the most powerful predictors of QoL, however latest advances in pharmacological treatment (namely, anti-TNF-α) along with physical exercise can minimize the effects of AS on QoL. Psychological distress symptoms contribute to impaired QoL both directly and indirectly by influencing disease activity. The impact of other psychosocial variables, however, is less studied and more prospective investigations are necessary, which could eventually lead to the development of psychosocial interventions that are personalized to this patient population.

Therapeutic options after treatment failure in rheumatoid arthritis or spondyloarthritides

The prognosis for patients with rheumatoid arthritis or spondyloarthritides has improved dramatically due to earlier diagnosis, recognition of the need to treat early with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), alone or in combinations, the establishment of treatment targets, and the development of biological DMARDs (bDMARDs). Many patients are now able to achieve clinical remission or low disease activity with therapy, and reduce or eliminate systemic corticosteroid use. Guidelines recommend methotrexate as a first-line agent for the initial treatment of rheumatoid arthritis; however, a majority of patients will require a change of csDMARD or step up to combination therapy with the addition of another csDMARD or a bDMARD. However, treatment failure is common and switching to a different therapy may be required. The large number of available treatment options, combined with a lack of comparative data, makes the choice of a new therapy complex and often not evidence based. We summarize and discuss evidence to inform treatment decisions in patients who require a change in therapy, including baseline factors that may predict response to therapy.

Safe re-administration of tumor necrosis factor-alpha (TNFα) inhibitors in patients with rheumatoid arthritis or ankylosing spondylitis who developed active tuberculosis on previous anti-TNFα therapy

There is no consensus on whether it is safe to re-administer tumor necrosis factor-alpha (TNFα) inhibitors in patients with rheumatoid arthritis (RA) or ankylosing spondylitis (AS) flared after withdrawal of TNFα inhibitors due to active tuberculosis (TB). We evaluated the safety of restarting anti-TNFα therapy in patients with TNFα-associated TB. We used data of 1,012 patients with RA or AS treated with TNFα inhibitors at Seoul St. Mary's Hospital between January 2003 and July 2013 to identify patients who developed active TB. Demographic and clinical data including the results of tuberculin skin tests (TST) and interferon-γ releasing assays (IGRA) were collected. Fifteen patients developed active TB. Five cases were occurred in RA and 10 cases in AS. Nine of 15 patients had a negative TST or IGRA and 6 TST-positive patients had received prophylaxis prior to initiating anti-TNFα therapy. All patients discontinued TNFα inhibitors with starting the treatment of TB. Eight patients were re-administered TNFα inhibitors due to disease flares and promptly improved without recurrence of TB. TNFα inhibitors could be safely resumed after starting anti-TB regimen in patients with RA or AS.

Long-term safety and efficacy of etanercept in the treatment of ankylosing spondylitis

To date, anti-tumor necrosis factor alfa (anti-TNF-α) therapy is the only alternative to nonsteroidal anti-inflammatory drugs for the treatment of ankylosing spondylitis. Etanercept is a soluble TNF receptor, with a mode of action and pharmacokinetics different to those of antibodies and distinctive efficacy and safety. Etanercept has demonstrated efficacy in the treatment of ankylosing spondylitis, with or without radiographic sacroiliitis, and other manifestations of the disease, including peripheral arthritis, enthesitis, and psoriasis. Etanercept is not efficacious in inflammatory bowel disease, and its efficacy in the treatment of uveitis appears to be lower than that of other anti-TNF drugs. Studies of etanercept confirmed regression of bone edema on magnetic resonance imaging of the spine and sacroiliac joint, but failed to reduce radiographic progression, as do the other anti-TNF drugs. It seems that a proportion of patients remain in disease remission when the etanercept dose is reduced or administration intervals are extended. Etanercept is generally well tolerated with an acceptable safety profile in the treatment of ankylosing spondylitis. The most common adverse effect of etanercept treatment is injection site reactions, which are generally self-limiting. Reactivation of tuberculosis, reactivation of hepatitis B virus infection, congestive heart failure, demyelinating neurologic disorders, hematologic disorders like aplastic anemia and pancytopenia, vasculitis, immunogenicity, and exacerbation or induction of psoriasis are class effects of all the anti-TNF drugs, and have been seen in patients with ankylosing spondylitis. However, etanercept is less likely to induce reactivation of tuberculosis than the other anti-TNF drugs and it has been suggested that etanercept might be less immunogenic, especially in ankylosing spondylitis. Acute uveitis, Crohn's disease, and sarcoidosis are other adverse events that have been rarely associated with etanercept therapy in patients with ankylosing spondylitis.

Low doses of etanercept can be effective to maintain remission in ankylosing spondylitis patients

We wanted to do a prospective open-label study to evaluate if ankylosing spondylitis (AS) patients in clinical remission with twice weekly etanercept (ETN) 25 mg therapy could be changed to weekly regimen or even to every other week regimen without increased dose for injection. Thirty-eight AS patients self-administered 25 mg of ETN (Wyett) subcutaneously. According to the protocol, patients who were in clinical partial remission with twice weekly ETN 25 mg at week 12 and 16 changed to a weekly regimen without a change of the dose. If clinical remission, despite the reduction of the dose, persists at week 24 and 28, patients changed to an every-other-week regimen, continuing with this administration schedule for the entire duration of the study if at week 36 and 46 clinical remission was maintained. At the end of the study, 18 patients (47 %) were still in remission, 4 (10 %) with a weekly regimen, and 14 (37 %) with an every-other-weekly regimen. Our study indicates that a consistent percentage of subjects with AS, treated with ETN 25 mg twice weekly, achieved clinical remission within the first 3 months of therapy, and also, a substantial percentage of these patients maintains the partial remission with an every other week regimen.

Crohn's disease unmasked following etanercept treatment for ankylosing spondylitis

We describe the case of a 45-year-old man with ankylosing spondylitis being treated with etanercept who presented with a 1 month history of abdominal pain. CT abdomen revealed an ileocaecal mass associated with an abscess, resulting in a laparotomy and right hemi-colectomy. Histology of the resected specimen showed the classical features of Crohn's disease. Etanercept was stopped and he was started on adalimumab. He is currently in clinical remission from both ankylosing spondylitis and Crohn's disease.

Emerging drugs for axial spondyloarthritis including ankylosing spondylitis

INTRODUCTION

Only non-steroidal anti-inflammatories (NSAIDs) and TNF inhibitors (TNFi) are effective in ankylosing spondylitis (AS). However, not all patients successfully respond to these drugs and a subset may have contraindications to their use.

AREAS COVERED

In the last decade, an earlier diagnosis of AS has been achieved due to the increasing availability of MRI. This has led to prompt treatment initiation with improved outcomes. NSAIDs and TNFi are the current treatments for AS which lead to sustained clinical responses in the long term. Recent studies have shown other potential biomarkers in AS, such as the IL-17/IL-23 axis. This has translated into the development of new drugs which interfere with these pathways, such as apremilast and secukinumab, which have shown efficacy in early clinical trials.

EXPERT OPINION

AS carries considerable short- and long-term disabilities. Anti-TNF-α therapies reduce pain, improve function and decrease inflammation as seen by MRI. New treatment options are being developed which may prove efficacious on those patients not responding to anti-TNF. The ultimate research goal should focus on treatments to prevent and stop new bone formation.

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.

Can we reduce the dosage of biologics in spondyloarthritis?

TNF blockers have revolutionized the management of spondyloarthritis (SpA). To date, four anti-TNFα agents (etanercept, infliximab, adalimumab, golimumab) have been approved for the management of ankylosing spondylitis (AS) and psoriatic arthritis (PsA). The first objective in the management of AS and PsA with TNF inhibitors is to reduce disease activity to clinical remission or low disease activity. After remission has been achieved, this state should be maintained as long as possible. However, the financial burden associated with the cost of anti-TNF agents as well as concerns about their long-term safety suggest reducing the dosage of the drug or discontinuing the therapy in the hopes of drug-free remission. The aim of this review is to examine what has, till now, been published on this topic in axial SpA, which includes AS and non-radiographic axial SpA (nr-axSpA), peripheral SpA and PsA. Discontinuation of therapy in axial SpA is not possible in the majority of patients, while on the contrary, reducing the dosage often is. In some patients with peripheral SpA and PsA it is also possible to discontinue therapy and to achieve drug-free remission.

Anti-TNF Therapy in Ankylosing Spondylitis: Insights for the Clinician

The introduction of tumour necrosis factor (TNF)-blocking therapy has revolutionized the management of ankylosing spondylitis (AS) over the last decade. This review highlights the current evidence relating to the use of TNF-blocking therapy in AS. International guidelines for the use of TNF blockers in AS are summarized. An outline of the evidence for efficacy and safety of these drugs is included, highlighting recent data from registries and real-life observational studies. Such cohort data is also reviewed highlighting the evidence for 'switching' TNF blockers in AS in the case of non-response or adverse events. The potential new application of TNF blockers in preradiographic axial spondyloarthropathy (SpA) or 'early AS' is discussed with reviews of two recent studies in this area. Finally research into the possible additional impacts of TNF therapies is reviewed. The question of whether TNF blockers are truly disease modifying in AS remains unanswered with conflicting reports. The additional burden of AS in terms of cardiovascular disease is now becoming understood. Recent data from basic science studies highlights the potential impact of TNF blockers on this excess cardiovascular morbidity and mortality. Future studies and registry data will be able to assess whether TNF blockers have an additional role in controlling systemic inflammation and its associated cardiovascular risk.

Etanercept in the treatment of ankylosing spondylitis: a meta-analysis of randomized, double-blind, placebo-controlled clinical trials, and the comparison of the Caucasian and Chinese population

BACKGROUND AND PURPOSE

Ankylosing spondylitis (AS) is a kind of rheumatic disease, leading to pain, fatigue, stiffness, and functional impairment, which seriously affects the quality of life. Etanercept, a fully human recombinant protein, has been applied for the treatment of AS. However, there has not been a systematic analysis for its efficacy and safety.

METHODS

This meta-analysis of fourteen randomized, double-blind, placebo-controlled clinical trials with 1,570 participants was performed to investigate the efficacy and safety of etanercept, by means of calculating the overall relative risk, and to compare the different responses between the Caucasian population and the Chinese population.

RESULTS

Generally, there was sufficient evidence to prove that etanercept has its advantages in both disease activity controlling and symptoms relieving, especially for axial joints compared with peripheric joints, without higher incidence of serious adverse events.

INTERPRETATION

Our preliminary analysis provided that the Caucasian population has better response to etanercept treatment, with more treatment-emergent adverse events. Further specially designed clinical trials need to be performed to investigate the different responses between axial and peripheric joints, also between different races.

Dosage adjustment of anti-tumor necrosis factor-α inhibitor in ankylosing spondylitis is effective in maintaining remission in clinical practice

OBJECTIVE

While remission is possible in patients with ankylosing spondylitis (AS), it is often unclear what attitude should be adopted once remission has occurred. We investigated whether dosage adjustment is an effective means of maintaining remission.

METHODS

This was a retrospective study drawn from clinical situations. Remission was defined using clinical measures [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≤ 20/100 and no peripheral joint disease] and biological measures [C-reactive protein (CRP) levels ≤ normal value]. The tumor necrosis factor-α (TNF-α) inhibitors used were infliximab, adalimumab, and etanercept. Response predictors of remission were evaluated by logistic regression (age, CRP, HLA-B27 positivity, sex, duration of disease, and anti-TNF-α naivety). CRP and BASDAI were evaluated before and after dosage adjustment at about 6, 12, 24, and 36 months.

RESULTS

One hundred eighty-nine patients with AS were included in the study, with a mean followup of 43.5 (± 17.9) months after the introduction of the first anti-TNF-α inhibitor. Mean age was 45.6 (± 12.5) years. Remission had occurred in 65 patients (35%). Significant response predictors of remission were male sex (p = 0.003) and anti-TNF-α naivety (p < 0.001). Dosage adjustment was observed 49 times, and progressively reducing treatment frequency was effective to maintain remission in a large number of patients for 36 months. The cumulative probability of continuing anti-TNF-α after dosage adjustment was 79.0% at 12 months, 70.5% at 24 months, and 58.8% at 36 months.

CONCLUSION

Remission had occurred in 35% of the patients with AS under anti-TNF-α inhibitor therapy. Dosage adjustment and progressively reducing treatment frequency was effective in maintaining remission.

Economic considerations of the treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is associated with both significant direct and indirect costs, which vary by country, and have generally increased dramatically since the introduction of anti-tumor necrosis factor therapy. The cost-effectiveness of biologic agents is controversial, although cost-effectiveness studies need to consider the potential impact of anti-tumor necrosis factor treatments on work ability. Alternatives to reduce costs associated with biologics have been examined, including on-demand dosing and lower dose alternatives. Other treatment measures, such as total hip arthroplasty and physical therapy, are also effective in reducing pain and improving function in patients with AS, although the optimal type or combination of physical therapy treatment modalities, the optimal frequency and duration of treatment and whether therapy is equally effective in stable disease and uncontrolled AS need to be determined. No studies have examined differences in patient outcomes based on subspecialty care. Establishing an evidence base for these questions would help inform policy decisions to design the most cost-effective measures to treat AS.

[How to optimize the antiTNF alpha therapy in spondylitis?]

TNFalpha inhibitors have been a major advance in the treatment of spondyloarthropathies, having demonstrated their safety and efficacy, with higher response and survival rates than those observed in patients with rheumatoid arthritis. The fact that disease modifying anti-arthritic drugs (DMARD) have shown utility in the treatment of this disease, especially in the axial forms, gives them greater importance, since it is known that up to 30%of patients do not respond to treatment with non-steroidal anti-inflammatory drugs. However, we must take into account that these drugs are expensive and not without side effects, so it is necessary to optimize their use. We intend to review the use of antiTNF alpha in spondyloarthropathies and review the available evidence on strategies that can help with their rational use.

Etanercept use for psoriasis in Taiwan: a case series study

BACKGROUND

The reported efficacy and safety of some biologic agents for psoriasis vary between Caucasians and Asians. Few reports of etanercept exist in psoriasis patients within the Asia-Pacific region.

OBJECTIVES

The study aims to report our clinical experience of etanercept in the treatment of patients with moderate-to-severe psoriasis in Taiwan.

METHODS

A retrospective analysis of 59 patients with moderate-to-severe psoriasis who received etanercept was conducted in a tertiary referral center.

RESULTS

Etanercept therapy resulted in a reduction of mean Psoriasis Area and Severity Index (PASI) of 47% at week 12 and 61% at week 24. After 12 weeks of treatment, 48%, 26%, and 3.4% of the patients achieved at least PASI50, 75 and 90 response, respectively. At week 24, the proportion of patients achieving at least PASI50, 75 and 90 response was 59%, 37%, and 14%, respectively. Etanercept efficacy in achieving PASI75 improvement was, however, lower than that reported in previous pivotal placebo-controlled trials. No cases of active tuberculosis, viral hepatitis or malignancies were observed during the observation period.

CONCLUSION

Our case series demonstrated the efficacy and safety of etanercept for the management of moderate-to-severe psoriasis in Taiwan.

Etanercept in the treatment of recalcitrant enteropathic arthritis: a case report

Introduction

Enteropathic arthritis is one of the recognized extraintestinal manifestations of inflammatory bowel disease and affects up to 25% of patients. The treatment options for refractory disease were rather limited and ineffective until the arrival of biologic therapy in the last few years. The use of etanercept was unique for this disease.

Case presentation

In this case report, a 58-year-old Malay woman with a 17-year history of ulcerative colitis had persistent left knee effusion and synovitis for seven years, despite remission of the primary disease. She had had multiple courses of systemic and intra-articular steroid that caused significant systemic side effects such as impaired fasting glucose, hypertension, cataract, and weight gain. She also had a total left knee replacement for secondary osteoarthritis. But the left knee synovitis and effusion recurred a month after the total knee replacement, and she was subjected to a total synovectomy the following year. In view of failure of remission despite multiple immunosuppressants (100 mg of azathioprine daily, 1 g of sulfasalazine twice a day, 10 mg of prednisolone daily, and 10 mg of methotrexate weekly), 25 mg of subcutaneous etanercept twice weekly was started. After 5 weeks of treatment, complete resolution of left knee effusion and normalization of the inflammatory markers were shown. This continued up to 12 months of follow-up while our patient was on etanercept and 10 mg of methotrexate weekly. No relapse or serious side effects were noted.

Conclusions

This case demonstrates the efficacy of etanercept in recalcitrant enteropathic arthritis with no relapse of the underlying colitis while on treatment. The usage of this tumor necrosis factor inhibitor was unique in this case of rheumatology and gastroenterology.

Development of inflammatory bowel disease during anti-TNF-α therapy for inflammatory rheumatic disease: a nationwide series

OBJECTIVES

To describe cases of new onset of inflammatory bowel disease (IBD) in patients with inflammatory rheumatic disease (IRD) receiving anti-TNF-α therapy.

METHODS

A call for observations of such cases was sent to members of the French "Club rhumatismes et inflammation". Only patients without intestinal symptoms before introduction of anti TNF-α agents were included.

RESULTS

During a 2-year period, 16 patients were declared: nine men and seven women, mean age 41.5 ± 17.4 years, 12 patients with ankylosing spondylitis, one with rheumatoid arthritis, one with psoriatic arthritis and two juvenile idiopathic arthritis with enthesitis related arthritis. Overall, 14 patients received etanercept and two had infliximab. The meantime frame between onsets of anti-TNF--α drugs and development of IBD was 29.3 ± 20.1 months. According to endoscopic and histological findings, IBD was classified as typical Crohn's disease in eight cases, Crohn's-like disease in six cases, indeterminate in one case and definite ulcerative colitis in one case. For all cases, each TNF-α blocking agent was discontinued and replaced by another monoclonal anti TNF-α antibody. After a mean follow up period of 23.4 ± 19.5 months, outcome was favorable without recurrent or flaring IBD.

CONCLUSIONS

Paradoxical IBD may occur during anti TNF-α therapy for inflammatory rheumatic disease, mostly in patients with spondylarthropathies while receiving etanercept, at a frequency estimated to 0.15% in the French patients with spondylarthropathies exposed to TNF-α antagonists. The IBD mainly corresponded to Crohn's or Crohn's-like disease. On the contrary, new onset IBD is less frequently observed in other cases of IRD and with other TNF--α blockers.

Tumor necrosis factor-blocking agents for children with enthesitis-related arthritis--data from the dutch arthritis and biologicals in children register, 1999-2010

OBJECTIVE

To evaluate the effectiveness and safety of biological agents in children with enthesitis-related arthritis (ERA).

METHODS

All patients with ERA in whom a biological agent was initiated between 1999 and 2010 were selected from the Dutch Arthritis and Biologicals in Children (ABC) register. In this ongoing multicenter observational register, data on the course of the disease and medication use are retrieved prospectively at the start of the biological agent, after 3 months, and yearly thereafter. Inactive disease was assessed in accordance with the Wallace criteria.

RESULTS

Twenty-two patients with ERA started taking 1 or more biological agents: 20 took etanercept, 2 took adalimumab (1 switched from etanercept to adalimumab), and 2 took infliximab (1 switched from etanercept to infliximab). Characteristics: 77% were male, 77% had enthesitis, 68% were HLA-B27-positive. The median age of onset was 10.4 (IQR 9.4-12.0) years; median followup from the start of the biological agent was 1.2 (IQR 0.5-2.4) years. Intention-to-treat analysis shows that inactive disease was achieved in 7 of 22 patients (32%) after 3 months, 5 of 13 patients (38%) after 15 months, and 5 of 8 patients (63%) after 27 months of treatment. Two patients discontinued etanercept because of ineffectiveness, and switched to adalimumab (inactive disease achieved) or infliximab (decline in joints with arthritis after 3 months of treatment). One patient discontinued etanercept because of remission, but had flare and restarted treatment, with good clinical response. No serious adverse events occurred.

CONCLUSION

Tumor necrosis factor (TNF)-blocking agents seem effective and safe for patients with ERA that was previously unresponsive to 1 or more DMARD. However, a sustained disease-free state could not be achieved, and none discontinued TNF-blocking agents successfully.

Ankylosing spondylitis in a patient referred to physical therapy with low back pain

Low back pain (LBP) is one of the most common and costly medical conditions in the United States; various studies have reported up to 80% of the adult population will experience a significant episode of LBP sometime within their lifetime. Although many cases of LBP are related to the musculoskeletal system and appropriate for the care of the physical therapist (PT), some episodes of LBP have a systemic cause. Thus, it is the role of the PT to ensure each patient is appropriate for physical therapy intervention throughout the episode of care. When the patient's condition is not appropriate for physical therapy intervention, it is the PT's responsibility to refer the patient to other medical professions to ensure optimal patient care. The purpose of this case report is to describe a patient referred to PT who was diagnosed with ankylosing spondylitis. The patient presented initially to physical therapy with a diagnosis of LBP. However, after several visits her symptoms were inconsistent with mechanical LBP and thus required further medical consultation.

Structural damage in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis: traditional views, novel insights gained from TNF blockade, and concepts for the future

Structural changes of bone and cartilage are a hallmark of inflammatory joint diseases such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS). Despite certain similarities – in particular, inflammation as the driving force for structural changes – the three major inflammatory joint diseases show considerably different pathologies. Whereas RA primarily results in bone and cartilage resorption, PsA combines destructive elements with anabolic bone responses, and AS is the prototype of a hyper-responsive joint disease associated with substantial bone and cartilage apposition. In the present review we summarize the clinical picture and pathophysiologic processes of bone and cartilage damage in RA, PsA, and AS, we describe the key insights obtained from the introduction of TNF blockade, and we discuss the future challenges and frontiers of structural damage in arthritis.