Current Concepts in the Therapy of the Spondyloarthritides

Recent success in the treatment of patients with the more severe forms of spondyloarthritides (SpA) has dramatically changed old paradigms. There is evidence that anti-tumor necrosis factor (TNF)-α therapy is highly effective in SpA, especially in ankylosing spondylitis (AS) and psoriatic arthritis. Based on recent data on more than 1000 patients with AS and psoriatic arthritis, this treatment seems to be even more effective than in rheumatoid arthritis (RA). The currently available anti-TNFα agents, infliximab, etanercept, and adalimumab, are approved for the treatment of RA in the US and in Europe. TNFα blockers may even be considered as a first-line treatment in patients with active AS whose condition is not sufficiently controlled with NSAIDs, as in the case of axial disease. There is preliminary evidence that both agents also work in other SpA, such as undifferentiated SpA. There is hope that ankylosis may be preventable, but it remains to be shown whether patients benefit from long-term anti-TNFα therapy and whether radiologic progression and ankylosis can be stopped. Furthermore, it seems that anti-TNFα therapy can also improve clinical manifestations of other inflammatory spinal disorders, such as sciatica and back pain caused by disc herniation, or possibly even intermittent inflammatory states of degenerative disc disease. Severe adverse events from treatment with anti-TNFα continue to be rare. Tuberculosis can be largely prevented by appropriate screening. As it stands now, the benefits of anti-TNFα therapy in AS seem to outweigh the shortcomings.