Experts Discuss Best Treatment Practices and Emerging Therapies for Axial Spondyloarthritis

Axial spondyloarthritis (AxSpA) is a chronic inflammatory disease affecting primarily the axial skeleton. Lack of awareness has made AxSpA, an umbrella term that includes nonradiographic AxSpA and ankylosing spondylitis (AS), an underdiagnosed condition. However, increased education efforts and new therapeutic options have improved the management of patients with AxSpA.

In a Specialty Pharmacy Times® Insights video series (specialtypharmacytimes.com/insights), experts Atul A. Deodhar, MD, and Hillary Norton, MD, discussed clinical best practices surrounding the diagnosis, management, and treatment of AxSpA, including an overview of available therapies.

Both Deodhar and Norton stressed the importance of distinguishing between nonradiographic and radiographic AxSpA. Nonradiographic disease is part of the same spectrum but may occur as early disease or be a separate entity that never progresses to radiographic disease. Misunderstanding is prevalent among providers, they said.

“The symptoms are the same, the treatment is the same, but we don’t know yet who will progress to radiographic disease, and everybody may not progress, particularly women,” Norton said.

Nonradiographic AxSpA and AS have a similar burden of disease, and both involve decreased quality of life, disability, missed time at work, and rising health care costs

Increased educational efforts can help improve diagnosis, which is instrumental to timely access to treatment for patients.

Additionally, the experts noted that accurately identifying which symptoms are indicative of AxSpA is a challenge. The signs and symptoms that are important to recognize involve a distinction between mechanical and inflammatory back pain. Individuals with AxSpA typically experience inflammatory back pain that starts before age 35, lasts for at least 3 months, and involves pain that is worse at night. However, often patients receive an inaccurate diagnosis of mechanical back pain instead.

AxSpA differs from other rheumatologic conditions, such as rheumatoid arthritis and psoriatic arthritis, in terms of the pathophysiology of the joint damage. Although these conditions all start with bone erosion, patients with AxSpA go on to develop new bone formation. This can ultimately lead to reduced mobility of the spine.

Regarding primary therapeutic goals for patients, the experts emphasized minimizing symptoms, extra-articular complications, and complications of spinal disease, as well as maintaining function.

“We are looking to see that patients receiving these drugs are improving their quality of life not only by reducing signs and symptoms but also by reducing radiographic progression,” Deodhar added. “But currently, that is aspirational. We are heading there, but we are not there yet.”

The experts discussed the treatment options for AxSpA, including nonpharmacologic methods, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and tumor necrosis factor (TNF) inhibitors. Generally, clinicians should avoid opioids for the treatment of AxSpA, as these medications do not address the underlying cause of the disease.

According to Deodhar and Norton, exercise is the cornerstone of therapy for patients with AxSpA, but additional treatment with pharmacologic methods can further improve quality of life. Patients can use TNF inhibitors, in particular, if NSAIDs are insufficient.

“If patients have tried a couple of NSAIDs for the full dose for up to a month and they still have significant back pain, then we suggest starting biologic therapy,” Deodhar added.

TNF inhibitors have been very effective in treating AS, according to the experts. “In general, I would use these in a young, otherwise healthy patient who doesn’t have signs of acute or chronic infection,” Norton said.

Despite a lack of prospective clinical data, Deodhar noted that retrospective findings have indicated that patients treated with biologics, such as TNF inhibitors, for a long period experienced reduced rates of progression. Interleukin-17 (IL-17) inhibitors have also been beneficial when prior lines of therapy have failed.

“More recently, it has been found that [interleukin]-23/IL-17 axis is very important in the pathology of AS,” Deodhar said. “And this again was found to be high. IL-17 is high in the serum of patients with AxSpA.”

Both of these agents have completely changed the face of AxSpA treatment. Previously, treatment options were limited to the use of NSAIDs and physical therapy, as well as other drugs such as methotrexate and sulfasalazine, which have no role to play in AxSpA and AS, according to Deodhar. He noted that investigators are evaluating another class of drugs, Janus kinase inhibitors, for AxSpA and conducting new research in the microbiome.

“The treatment of this condition in the future might also be dependent on altering or modulating your gut microbiome,” Deodhar said.

Despite recent advancements, unmet treatment needs for AxSpA remain.

“TNF inhibitors and IL-17 inhibitors work very well for many of our patients, but we still have cases in which someone doesn’t respond to one of these biologics,” Norton said. “The pipeline includes new classes of medications. This will provide more options for these patients who don’t respond to the medications we currently have.”