Seminar

Axial spondyloarthritis
Joachim Sieper, Denis Poddubnyy

The term axial spondyloarthritis covers both patients with non-radiographic and radiographic axial spondyloarthritis, Lancet 2017; 390: 73–84
which is also termed ankylosing spondylitis. The disease usually starts in the third decade of life with a male to female Published Online
ratio of two to one for radiographic axial spondyloarthritis and of one to one for non-radiographic axial spondyloarthritis. January 19, 2017
http://dx.doi.org/10.1016/
More than 90% heritabilty has been estimated, the highest genetic association being with HLA-B27. The pathogenic
S0140-6736(16)31591-4
role of HLA-B27 is still not clear although various hypotheses are available. On the basis of evidence from trials the
Department of
cytokines tumour necrosis factor (TNF)-α and interleukin-17 appear to have a relevant role in pathogenesis. The Gastroenterology, Infectious
mechanisms of interaction between inflammation and new bone formation is still not completely understood but Diseases and Rheumatology,
clarification will be important for the prevention of long-term structural damage of the bone. The development of new Campus Benjamin Franklin,
Charité Universitätsmedizin
criteria for classification and for screening of patients with axial spondyloarthritis have been crucial for the early
Berlin, Berlin, Germany
indentification and treatment of such patients, with MRI being the most important existing imaging method. (Prof J Sieper MD,
Non-steroidal anti-inflammatory drugs and TNF blockers are effective therapies. Blockade of interleukin-17 is a new Prof D Poddubnyy MD)
and relevant treatment option. Correspondence to:
Prof Joachim Sieper, Department
Introduction second part of the night. Different sets of criteria have of Gastroenterology. Infectious
Diseases and Rheumatology,
Axial spondyloarthritis is a chronic inflammatory disease been developed for the classification of inflammatory Charité, Campus Benjamin
that mainly affects the axial skeleton. It is a type of back pain, which are largely overlapping.7–9 However, the Franklin, Hindenburgdamm 30,
spondyloarthritis, which also includes psoriatic arthritis, sensitivity and specificity of any of these criteria for the Berlin 12203, Germany
joachim.sieper@charite.de
arthritis associated with inflammatory bowel disease, diagnosis of axial spondyloarthritis is not higher than
and reactive arthritis. The term axial spondyloarthritis about 80%, meaning that not every axial spondyloarthritis
covers both patients who have already developed patient has this kind of back pain and that this symptom
structural damage in the sacroiliac joints or spine visible is also present in a substantial proportion of patients with
on radiographs (radiographic axial spondyloarthritis, also chronic back pain of other causes. Inflammation and, as a
termed ankylosing spondylitis) and patients without consequence of inflammation, structural damage can
such structural damage, labelled as non-radiographic occur in the axial skeleton, which can result in restriction
axial spondyloarthritis. of spinal mobility. This restriction can be quantified by
Non-radiographic axial spondyloarthritis can be seen applying established methods (such as the modified
as an earlier or milder part of axial spondyloarthritis Schober test for measurement of lumbar flexion).10,11
and patients might or might not develop structural Arthritis and enthesitis are the most common
boney damage in the axial skeleton. The Assesment peripheral manifestations (found in 30–50% of axial
in Spondylo-Arthriits international Society (ASAS) spondyloarthritis at presentation or in the past), which
has published new classificaiton criteria for axial can occur at any time in the course of the disease. These
spondyloarthritis.1 The development of the new criteria manifestations are predominantly found in the lower
was necessary because the older modified New York limbs, frequently in an asymmetrical fashion. The joints
criteria for anklyosing spondylitis2 did not allow are generally swollen and painful. Inflammation at the
identification of axial spondyloarthritis patients early in insertion of tendons, ligaments, or capsule into bone is
the course of the disease in the absence of radiographic called enthesitis. A typical location is at the insertion of
changes in the sacroiliac joints, which can take years the Achilles tendon or the plantar fascia at the calcaneus,
to manifest. Other criteria such as the European but inflammation is possible at any enthesial site.
Spondyloarthropathy Study Group (ESSG)3 and the A rather rare peripheral manifestation in axial is
Amor criteria4 had not yet included MRI assessment. The
term axial spondyloarthritis should be used preferentially
for diagnosis and classification, unless medical reasons Search strategy and selection criteria
are present to differentiate between ankylosing We searched for original English language articles and reviews
spondylitis or non-radiographic axial spondyloarthritis.5,6 in MEDLINE (via PubMed) published between Jan 1, 2000,
and April 30, 2016, using the following search terms:
Clinical presentation “ankylosing spondylitis” or “spondyloarthritis” in
Patients present with chronic back pain and stiffness combination with the terms “diagnosis”, “pathogenesis”,
predominantly of the pelvis and the lower back, but any “imaging”, “management”, “treatment”. We largely selected
part of the spine can be involved. Typical is inflammatory publications in the past 5 years, but did not exclude
back pain, which is clinically defined. Patients complain commonly referenced and highly regarded older publications.
of morning stiffness mostly of the lower back with We also searched the reference lists of articles identified by
improvement on exercise but not by rest. They can also be the search strategy and selected those we judged relevant.
awakened by back pain in the night, typically in the

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dactylitis, which is a swelling of a finger or toe as the in African-Americans, ankylosing spondylitis occurs
consequence of tendovaginitis. Disease activity is less frequently.20 The pooled prevalence for all types of
generally quantified by the Bath Ankylosing Spondylitis spondyloarthritis (including peripheral forms) ranges
Disease Activity Index (BASDAI)12 or the Ankylosing from 0·20% in South-East Asia to 1·61% in Northern
Spondylitis Disease Activity Score (ASDAS)13—both are Arctic communities.19 The reported prevalence of axial
composite scores. ASDAS contains an acute phase spondyloarthritis is between 0·32% and 1·4% in
reactant, usually C-reactive protein (CRP), in addition to different surveys.21–23
a patient’s reported outcome indices.
Uveitis is the most frequent extra-articular Pathogenesis
manifestation and presents typically as uveitis anterior, is Most studies of pathogenesis, especially those of genetics,
limited in duration, acute in onset, unilaterally, and have focused in the past on ankylosing spondylitis, which
frequently alternating from one eye to the other. Psoriasis constitutes a more homogeneous group than do all
and inflammatory bowel disease are less frequent patients with axial spondyloarthritis (figure 1). On the
See Online for appendix extra-articular findings (appendix).14–16 basis of studies of twins with ankylosing spondylitis
greater than 90% heritabilty has been estimated.24
Epidemiology Genome-wide association studies (GWAS) have detected
The disease usually starts in the third decade of life, and several genes associated with ankylosing spondylitis.
about 5 years earlier in HLA-B27 positive patients than In one large such study,25 20·44% of the genetic
in HLA-B27-negative patients.15,17 Slightly more patients predispositon was attributable to major histocompatibility
with ankylosing spondylitis are male than female complex (MHC) variants (mainly HLA-B27, but also
(approximate male to female ratio is 2–3:1); whereas the HLA-B40, HLA-B51, HLA-B7, HLA-A2, and HLA-DPB1),
sex distribution among patients with non-radiographic and 7·38% to non-MHC variants. The remaining 72% of
axial spondyloarthritis is equal.15,18 Accurate prevalence genetic predisposition remains to be identified.
figures are difficult to obtain for axial spondyloarthritis In addition to HLA-B27, two further genetic loci have
because studies rely on a selection of patients or been associated with ankylosing spondylitis and might be
population-based surveys that generally do not include of functional relevance: endoplasmic reticulum amino­
imaging investigations and HLA-B27 testing. More data petidase (ERAP),26 which encodes an aminopeptidase
are available for the prevalence of ankylosing spondylitis expressed in the endoplasmic reticulum and is involved in
than are for axial spondyloarthritis as a whole. The preparing peptides for MHC class 1 presentation to
prevalence of ankylosing spondylitis mirrors the immune effector cells, and the interleukin-23 receptor,26
prevalence of HLA-B27 in a given population. In which activates T-helper cells secreting the cytokine
populations of European descent HLA-B27 is present interleukin-17 but also other proinflammatory cells. The
in about 8% and ankylosing spondylitis in about 0·5%.19 ERAP1-association—but not the ERAP2-association—is
In those with a lower HLA-B27 prevalence, for example confined to HLA-B27-positive cases, indicating that
peptides presented by HLA-B27 might be of relevance.27
Axial spondyloarthritis is clincially associated with
Genetic background Disturbed Disturbed Infection inflammatory bowel disease, psoriasis, or reactive
HLA-B27
ERAP-positive
+ gut barrier
(Crohn’s)
Or skin barrier
(psoriasis)
Or
arthritis in about 15–20% of cases.14,15 However, any of
Interleukin-23 receptor these diseases can be clinically silent;28,29 therefore, this
Other identified and unidentified genes association might be much higher. Thus, barrier damage
of dermal (psoriasis) and mucosal (inflammatory bowel
Exposure to microbes disease) surfaces and the subsequent exposure of the
immune system to microorganisms seems to be of
relevance for the pathogenesis. Considerable overlap
Mediated by mechanical stress
between ankylosing spondylitis susceptibility loci and
inflammatory bowel disease loci has been found.26 An
altered microbiota has been identified in patients with
Sacroiliitis/spondylitis/enthesitis (inflammation) inflammatory bowel disease30 and intestinal microbiota
could also play an important part in spondyloarthritis.31,32
Anti-CD74 antibodies (directed against the class
Facultative
Repair: fibrous tissue invaded subchronal area 2-associated invariantchain peptide, CLIP), might play a
part in the diagnosis of axial spondyloarthritis and might
New bone formation: activation of osteoblasts
be implicated in its pathogenesis by binding to CD74 on
the surface of immune competent cells.33,34 However,
these findings need confirmation in larger studies.
Figure 1: Pathogenesis of axial spondyloarthritis
Inflammation might or might not (facultative) lead to repair and new bone formation. Molecular and cellular On the basis of therapeutic successes, two pathways in
aspects are not presented. ERAP=endoplasmic reticulum aminopeptidase. the inflammatory responses, probably located rather at

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the end of the immune response hierarchy, have attracted in the serum of patients with ankylosing spondylitis were
a lot of interest over past years—ie, the tumour necrosis associated with more syndesmophyte formation in the
factor (TNF)-α-axis and the the interleukin-23/ spine. Furthermore, higher levels of noggin-IgG, or
interleukin-17-axis. T-helper-17 cells release the cytokine sclerostin-IgG, or both, immune complexes have been
interleukin-17 on stimulation with interleukin-23. identified in the serum of patients with ankylosing
However, interleukin-17 is not only released by T cells but spondylitis, which might contribute to the increase
is also expressed by cells of the innate immune system in new bone formation in such patients.48 Several
such as mast cells and granulocytes in affected tissue biomarkers positively associated with the development of
of patients with ankylosing spondylitis35 and psoriatic structural damage in the spine have also been identified:
arthritis, and by mucosal-associated invariant cells in C-reactive protein (CRP),49 matrix-metalloproteinase-3,50
such patients.36 Human mast cells do not produce vascular endothelial growth factor,51 calprotectin,52 and
interleukin-17 themselves but actively capture exogenous visfatin.53 These biomarkers might help to identify
interleukin-17 through receptor-mediated endocytosis, patients at high risk for radiographic spinal progression;
which can then subsequently be released on stimulation.37 however, only CRP is currently recommended for use in
How the TNFα and interleukin-17-pathways are clinical practice.
connected and whether or not there is a hierachical MRI studies have been used to get a better idea about
order between the two is not clear.38 Interleukin-17 also the sequence of events from inflammation to new bone
inhibits bone formation, an effect that might be formation in the axial skeleton. These studies have
blocked pharmacologically by inhibiting interleukin- suggested that active inflammatory lesions (bone marrow
17A,39 although the exact effect of interleukin-17 on new oedema visible on MRI) later evolve into repair lesions
bone formation still needs to be clarified. (visible as fatty lesions on MRI) from which stimuli
Systemic overexpression of interleukin-23 in an animal for new bone formation are released.54,55 A recent
model induced an enthesitis, which resembles the one immunohistological study56 from facet joints from
seen in spondyloarthritis, supporting the idea that patients with ankylosing spondylitis, showed that a
interleukin-23 might play a pathogenic part for fibroblast-rich granulation tissue erodes the subchondral
enthesitis.40 In the context of axial spondyloarthritis it bone plate but also has bone-forming capacities. This
was of special interest that these cells ([ROR-γt]+CD3+CD4– granulation tissue was only partly associated with
CD8– T-cells) secrete interleukin-17 to activate osteoclasts adipocytes and fat vacuoles and might therefore evade
but could also release interleukin-22 upon stimulation detection by MRI T1-weighted sequence.55,57
with interleukin-23, which can induce osteoproliferation.
Interleukin-23 is expressed in the subchondral bone Classification criteria for axial spondyloarthritis
marrow in a higher amount in the spine from patients In 2009, the ASAS criteria for axial spondyloarthritis1
with ankylosing spondylitis than in subchondral bone (figure 2) and in 2011 for peripheral spondyloarthritis,58
marrow in the spine from osteoarthritis patients.41 were published, which differentiate between patients
The characteristic inflammation of spondyloarthritis with predominantly axial and patients with predominantly
occurs at the interface between cartilage and bone in the peripheral manifestations and that include MRI findings
sacroiliac joints, the spine, and the entheses. Mechanical
stress might be important for the initiation (and possibly In patients with ≥3 months back pain and age at onset <45 years
the maintainance) of inflammation42 and might explain
why the disease process most affects the weight bearing Sacroiliitis on imaging* HLA-B27
parts of the skeleton. In addition to inflammation, axial plus or plus
spondyloarthritis is also characterised by new bone ≥1 feature of spondyloarthritis ≥2 other features of
spondyloarthritis
formation in the sacroiliac joints and spine. New
bone formation seems to be the consequence of previous
bone damage42 and might be part of a repair process
aiming for stabilisation.43 Investigation of facet joints Spondyloarthritis features:
• Inflammatory back pain • Dactylitis • Family history
obtained from patients with ankylosing spondylitis showed • Arthritis • Psoriasis for SpA
that cartilaginous fusion and ankylosis of facet joints in • Enthesitis (heel) • Crohn’s/colitis • HLA-B27
such patients is promoted by cartilage degeneration and • Uveitis • Good response to NSAIDs • Elevated CRP

not mediated by chondrocyte hypertrophy.44

Figure 2: The ASAS classification criteria for axial spondyloarthritis
At the molecular level, osteoproliferation in axial
Adapted from Rudwaleit and colleagues.1 Overall sensitivity of the criteria is
spondyloarthritis seems to be directed by bone 82·9%, overall specificity is 84·4%. Imaging arm alone: sensitivity, 66·2%;
morphogenetic proteins, Wingless pathway proteins, specificity, 97·3%. Clinical arm alone: sensitivity, 56·6%; specificity, 83·3%.
hedgehog proteins, and fibroblast growth factors and ASAS=Assessment of SpondyloArthritis International Society. CRP=C-reactive
protein. NSAIDs=non-steroidal anti-inflammatory drugs. SpA=spondyloarthritis.
their respective signalling cascades.43,45 Osteoproliferation
*Sacroiliitis on imaging refers to definite radiographic sacroiliitis according to
is inhibited43 by molecules such as sclerostin, dickkopf 1, the modified New York criteria or sacroiliitis on MRI according to the ASAS
and noggin, and low levels of sclerostin46 and dickkopf 147 consensus definition.

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and HLA-B27 testing. However, because axial and spondyloarthritis and related disorders), and several
peripheral spondyloarthritis can overlap and exist laboratory indices (HLA-B27 and acute phase reactants
together, criteria were also developed for patients testing, and imaging findings) have to be combined for
presenting with both axial and peripheral classification and diagnosis of axial spondyloarthritis
spondyloarthritis.58 Because the disease usually starts in with only a moderate overlap between the two.
the sacroiliac joints, chronic or active inflammatory bony The same clinical, laboratory, and imaging indices are
changes of the spine are not part of the classification used for classification and diagnosis but clear differences
criteria but involvement of the spine without sacroiliac exist in their application.67,68 Classification criteria are
joints can occur in a small percentage of patients and developed to get a clear yes or no answer, to create a rather
could be used for diagnosis. The so-called clinical arm, homogeneous group of patients, usually for inclusion into
for which the presence of a positive HLA-B27 test is a clinical trial or cohort. For diagnosis, negative findings
mandatory, was added to the classification criteria to are also taken into account (appendix) and other reasons
increase sensitivity, resulting in an acceptable senstivitiy why typical indices of spondyloarthritis are positive have
of 82·9% and specificity of 84·4%. to be considered for differential diagnosis.69
Discussion is ongoing about whether these
classification criteria need modification, mostly for the Imaging
improvement of specificity.5,6,59–61 When patients from the Imaging is crucial for the correct (and early) diagnosis as
original study1 were followed up over 3–5 years and seen well as differential diagnosis of axial spondyloarthritis.
again by the local rheumatologist the positive predictive Because the disease affects sacroiliac joints (as opposed
value that patients who fulfilled the criteria initially to the spine) in most patients, imaging of sacroiliac
would still be diagnosed as axial spondyloarthritis by the joints has a pivotal role for diagnosis (and to a further
rheumatologist was 93·3%.62 Futhermore, when the extent in classification) of axial spondyloarthritis.10
ASAS classification criteria were tested in other cohorts Conventional radiography of the sacroiliac joints
with the rheumatologist’s diagnosis as the gold standard, (figure 3, appendix) is recommended as the first imaging
an acceptable sensitivity and specificity was comparable method to diagnose sacroiliitis as part of axial
with the initial study, resulting in a sensitivity of spondyloarthritis.2,69,70 Even in patients with short disease
between 68% and 87% and a specificity of between 62% duration (up to 3 years), a definite radiographic
and 95%.63–66 sacroiliitis could be seen in 30–50%, which would make
further diagnostic procedures unnecessary.71 Generally,
Diagnosis of axial spondyloarthritis this number depends predominantly on the duration of
Classification criteria are often wrongly used for disease at time of first diagnosis and has been reported
diagnostic purposes because separate diagnostic criteria to vary between 22% and 77%.60
are generally not available. Because of the lack of Nonetheless, radiography of sacroiliac joints has
gold standards in rheumatology, including axial limitations in patients with early axial spondyloarthritis,
spondyloarthritis, several clinical indices (presence of because structural changes generally take months to years
chronic back pain started at an age ≤45 years, to take place.72 Furthermore, the interpretation of
inflammatory back pain, peripheral and extraarticular radiographs of the sacroiliac joints is often challenging.
manifestations, response of symptoms to non-steroidal Indeed, a considerable inter-reader variation has repeatedly
anti-inflammatory drugs [NSAIDs], family history of been reported, even among experienced readers.73,74

A B C

T1
Figure 3: Radiograph of the sacroiliac joints
MRI of sacroiliac joints in a STIR and T1-weighted sequences of a 25-year-old patient with inflammatory back pain for about 1·5 years, positive HLA-B27, and slightly
raised C-reactive protein levels (7·2 mg/L). (A) Conventional pelvic radiograph shows some subchondral sclerosis on the right side, otherwise the joint is difficult to
assess; the latter is also true for the entire left sacroiliac joints, where an overlap with intestinal gas could be seen. No definite judgment on the presence or absence of
radiographic sacroiliitis could be made. (B) MRI in the STIR sequence shows two areas of bone marrow oedema (green arrows); the lesion in the right sacroiliac joint is
large and localised subchondrally and is therefore compatible with spondyloarthritis. The lesion on the left side is localised not directly subchondrally and might
represent the rest of a larger lesion or enthesitis. (C) MRI in the T1-weighted sequence shows large areas of fat metaplasia of bone marrow—so-called fatty lesions
(white arrows) localised subchondrally, sharply boarded, and homogeneous; further, subchondral sclerosis (pink arrows) and cortical bone defects (erosions, blue
arrow) are evident. Final diagnosis: axial spondyloarthritis. STIR=short TI-weighted inversion recovery.

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Normal or ambiguous radiographic results of sacroiliac anterior or posterior spondylitis in at least three sites;79
joints examination in the context of a possible diagnosis however, the presence of five or more inflammatory
of spondyloarthritis (figure 3, appendix) require MRI lesions might discriminate even better from control
investigation of the sacroiliac joints as the next step.70 groups.80 The diagnostic value of other imaging methods
The following MRI sequences are useful for diagnosis such as skeletal scintigraphy,81 ultrasonography of the
and differential diagnosis of axial spondyloarthritis sacroiliac joints, and positron emission tomography is
(figure 3, appendix): a T2-weighted sequence with fat low or undetermined in axial spondyloarthritis and,
suppression (such as a short tau inversion recovery therefore, these methods are not recommended
[STIR] sequence) for detection of active inflammatory for diagnosis.70
changes (bone marrow oedema) (figure 3, appendix); a
T1-weighted sequence for detection of post-inflammatory Screening in patients with chronic back pain
changes, such as erosions, sclerosis, ankyloses, and fatty A major delay of several years remains between the start
lesions (figure 3, appendix). A gradient echo sequence of chronic back pain and a final diagnosis in patients
(appendix),75 which allows better detection of erosions with axial spondyloarthritis. In addition to relying on
than a T1-weighted sequence because of improved the presence of radiographic changes that can take
contrast between bone and cartilage, can be helpful but is several years to develop, another reason is the difficulty
not yet used in routine care. The application of a contrast of diagnosing patients with axial spondyloarthritis in
agent is only rarely needed and does not usually provide the large number of chronic back pain patients in
more information in addition to the T2-weighted primary care.
sequence with fat suppression. Studies have tested different screening methods using
The ASAS group recently updated76 the definition of the presence of chronic (≥3 months) back pain starting at
an active sacroiliitis on MRI for classification of axial up to 45 years as an entry criterion in primary care.
spondyloarthritis. According to this definition, clear Generally one or a combination of possible screening
presence of bone marrow oedema on MRI in subchondral idicators have been applied. In nearly all these studies a
bone is mandatory (figure 3). Importantly, the appearance final diagnosis of axial spondyloarthritis was possible in
of bone marrow oedema has to be highly suggestive of 25–45%82–86 of patients referred from primary care to
spondyloarthritis, taking into account the size of the the rheumatologist. The percentage of patients with
lesions, its subchondral location and the exclusion of non-radiographic axial spondyloarthritis among those
other—mostly mechanical reasons—that could explain a diagnosed with axial spondyloarthritis after referral was
positive finding. The presence of post-inflammatory between 20% and 80%.60,84
structural changes, especially erosions, but also ASAS subsequently developed international recom­
subchondral sclerosis, fatty lesions, changes of the joint mendations for the early referral of patients with a
space should also be taken into account.70,76,77 suspicion of axial spondyloarthritis (appendix).87 These
CT of sacroiliac joints is regarded as a gold standard of recommendations include the entry criteria together
structural damage detection (especially erosions), but with any additional spondyloarthritis indices, which
conventional radiography and MRI of sacroiliac joints allows a more flexible approach and a selection of one or
usually allow a comprehensive assessment of structural several of these measures88 dependent on the regional
damage. However, CT of these joints (including a conditions.
so-called low-dose CT, which is associated with a low
radiation exposure) might be considered in cases of Management
inconclusive results.70 The existing international management recom­
The most common differential diagnoses for axial mendations (ASAS/EULAR89 and ACR/SAA/
spondyloarthritis are degenerative or mechanical problems SPARTAN ) are similar (figure 4). The approval of the
90

(degenerative disc disease, spondylosis, congenital interleukin-17 inhibitor secukinumab for treatment of
vertebral anomalies, diffuse skeletal hyperostosis, osteitis ankylosing spondylitis has already been integrated into
condensans [appendix], and osteoarthritis of sacroiliac the ASAS/EULAR recommendations.89 Treat-to-target
joints); other differential diagnoses such as fractures, recommendations for spondyloarthritis, including axial
infectious sacroiliitis, and bone metastasis or primary spondyloarthritis, psoriatic arthritis, and peripheral
bone tumours are less frequent. spondyloarthritis in general, were formulated in 2014 by
Imaging of the spine (radiography or MRI, appendix) an international task force.91 The main treatment target
is not usually required78 for early diagnosis because was defined as remission, with low disease activity
active inflammatory changes and structural damage regarded as a secondary target. For both radiographic
generally arise in the sacroiliac joints first, but might and non-radiographic forms axial spondyloarthritis,
also be considered as a part of differential diagnosis. On remission was defined by a low BASDAI score plus
the basis of a literature review and expert consensus, normal CRP values or by a low ASDAS,13 which includes
ASAS defined a positive (for active inflammation) spinal the results of measurements of CRP or erythrocyte
MRI in axial spondyloarthritis as the presence of sedimentation rate.

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cardiovascular, gastrointestinal, and renal risks.92 A

Predominant Axial manifestations: Peripheral manifestations: meta-analysis100 of randomised trials in patients with any
manifestation Back pain and stiffness arthritis, enthesitis, dactylitis
disease who were treated with NSAIDs for at least
First-line therapy NSAIDs
4 weeks, the relative risks of major adverse cardiovascular
events were 1·37 for celecoxib and 1·41 for diclofenac,
Non-pharmacological treatment: education, exercise, physical therapy,
rehabilitation, patient associations, self help groups
indicating no difference between cycloo­xygenase (COX)-2
selective and non-selective NSAIDs—with the exception
Local steroids of naproxen, which was not associated with an increase.
DMARDs sulfasalazine, methotrexate
Conventional disease modifying antirheumatic drugs
Second-line therapy TNF α blocker or IL-17 blocker and glucocorticoids
Conventional disease modifying antirheumatic drugs
Additional therapy Analgesics (DMARDs; as opposed to biological DMARDs—TNF and
and therapy in special
clinical situations Surgery interleukin-17 antagonists in axial spondyloarthritis),
such as methotrexate, sulfasalazine, or leflunomide, are
Figure 4: Recommendations for the treatment of axial spondyloarthritis generally not effective in the treatment of axial
Based on ASAS/EULAR89 and ACR/AAS/SPARTAN,90 including the current approval status for the interleukin-17 manifestations of spondyloarthritis, but these agents
blocker secukinumab. Secukinumab—an interleukin-17-antagonist—is currently approved only for ankylosing
might have a limited role for the treatment of peripheral
spondylitis. NSAIDs=non-steroidal anti-inflammatory drugs. DMARDs=disease modifying antirheumatic drugs.
TNF=tumour necrosis factor. manifestations when it coexists with axial disease.88,90
Discussion is ongoing over whether a combination of a
Non-steroidal anti-inflammatory agents conventional DMARD with a biological drug might
Non-steroidal anti-inflammatory agents (NSAIDs) are prevent the development of anti-drug antibodies (ADAs)
highly effective in reducing back pain and stiffness in directed against the biological drug and thus increases
patients with axial spondyloarthritis and are therefore the drug survival rate in these patients. However, such an
recommended as first-line treatment for these patients. advantage for a combination of a DMARD (mostly
There is no clear difference in the effectiveness of methotrexate) with a TNF blocker was shown in some
NSAIDs,92 and they are similarly effective in patients investigations101,102 of patients with axial spondyloarthritis
with ankylosing spondylitis and non-radiographic axial but not in others.103–105 Therefore, such a combination is
spondyloarthritis. Patients generaly respond in the first not recommended, which is also in line with current
2 weeks of NSAID therapy but in responders the response treatment recommendations.89,90
rate increases further during the first 24 weeks.93 NSAIDs Long-term systemic glucocorticoid therapy is not
should be used according to the patient’s symptoms. recommended because high doses of prednisolone of
Dose reduction or discontinuation should be tried if the about 50 mg per day106 or higher are needed to achieve a
patient is in remission. NSAIDs seem to be more effective measurable effect on disease acitvity.
if patients with axial spondyloarthritis are treated early in
the course of their disease, achieving a clinicial remission TNF inhibitors
rate of 35% in patients with early disease (<3 years of Five TNF inhibitors are available with approval for
disease duration)93 in comparison with about 12–15% in ankylosing spondylitis in the EC, USA, and most
patients with longstanding disease.94,95 other parts of the world: infliximab,107 etanercept,108
The safety of long-term NSAIDs therapy has been a adalimumab,109 golimumab,110 and certolizumab (table).111
concern. Longterm data for ankylosing spondylitis are Treatment with any of these TNF blockers leads to a good
limited and these data are mostly available for or very good improvement in all articular manifestations,
osteoarthritis and rheumatoid arthritis.92 Two reviews96,97 CRP levels, and MRI-detectable inflammation in the
of randomised controlled trials did not show increased sacroiliac joints or spine in active patients with ankylosing
side effects of NSAIDs therapy in ankylosing spondylitis spondylitis in whom conventional treatment with NSAIDs
compared with placebo during 12 weeks. Infrequent failed. Etanercept is not effective for active inflammatory
NSAID use was even associated with increased mortality bowel disease, by contrast with monoclonal antibodies,
in a Norwegian cohort of patients with long-term and evidence favouring monoclonal antibodies rather
ankylosing spondylitis,98 and in a population-based than etanercept is better for uveitis than for psoriasis.89,90
retrospective study99 of administrative health data from TNF blockers, with the exception of infliximab, have
Canada NSAID use was also associated with reduced also been approved for the other clinical subset of axial
cardiovascular risk in this population. NSAID treatment spondyloarthritis, non-radiographic spondyloarthritis, in
is associated with a decrease in inflammation and the European Union (EU) and elsewhere on the basis of
increased mobility in patients with axial spondyloarthritis, the results of phase 3 trials111,115–117 (table), but not yet in the
factors that might reduce cardiovascular morbidity. USA. The European label is restricted to patients with
Nonetheless, patients should be informed about the objective signs of inflammation, such as positive CRP or
potential risks of long-term treatment, including active MRI-inflammation in the sacroiliac joint or spine

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Dosing regimen Assessment Drug response Placebo response Difference, %

timepoint (ASAS40), % (n/N) (ASAS40), %
(week) (n/N)
Ankylosing spondylitis
Adalimumab109 40 mg, every other week, subcutaneous 12 40 (83/208) 13 (14/107) 27
Certolizumab pegol111 200 mg, every other week, subcutaneous 12 40 (26/65) 19 (11/57) 21
Certolizumab pegol111 400 mg, every 4 weeks, subcutaneous 12 50 (28/56) 19 (11/57) 31
Etanercept112 25 mg, twice weekly, subcutaneous 12 45 (58/128) 16 (21/129) 29
Golimumab110 50 mg, every 4 weeks, subcutaneous 14 45 (62/138) 15 (12/78) 30
Infliximab113 5 mg/kg, weeks 0, 2, and 6, and every 6 weeks thereafter, 24 47 (93/201) 12 (9/78) 35
intravenous
Secukinumab114 150 mg, subcutaneous, every 4 weeks, after initial 16 42 (52/125) 13 (16/122) 29
intravenous loading dose of 10 mg/kg at baseline, week 4
and 8
Secukinumab114 150 mg, subcutaneous, every 4 weeks, after initial loading 16 36 (26/72) 11 (8/74) 25
with 150 mg, subcutaneous, weekly through week 4
Non-radiographic axial spondyloarthritis (all included patients)*
Adalimumab115 40 mg, every other week, subcutaneous 12 36 (33/91) 15 (14/94) 21
Certolizumab pegol111 200 mg, every other week, subcutaneous 12 48 (22/46) 16 (8/50) 32
Certolizumab pegol111 400 mg, every 4 weeks, subcutaneous 12 47 (24/51) 16 (8/50) 31
Etanercept116 50 mg, weekly, subcutaneous 12 33 (35/105) 15 (16/108) 18
Golimumab117 50 mg, every 4 weeks, subcutaneous 16 57 (55/97) 23 (23/100) 34
Non-radiographic axial spondyloarthritis (with raised CRP, or active sacroiliitis on MRI, or both)*
Adalimumab115 40 mg, every other week, subcutaneous 12 41 (28/69) 14 (10/73) 27
Certolizumab pegol111 200 mg, every other week, subcutaneous 12 48 (22/46) 16 (8/50) 32
Certolizumab pegol111 400 mg, every 4 weeks, subcutaneous 12 47 (24/51) 16 (8/50) 31
Etanercept116,118† 50 mg, weekly, subcutaneous 12 35 (33/94) 17 (16/93) 18
Golimumab117 50 mg, every 4 weeks, subcutaneous 16 60 (47/78) 23 (18/80) 37

No data are available for infliximab and secukinumab for non-radiographic axial spondyloarthritis. These are not head-to-head trials and, therefore, comparison of results is
limited. Only the certolizumab trial was stratified for radiographic and non-radiographic axial spondyloarthritis, whereas the other trials for TNF blockers in radiographic and
non-radiographic axial spondyloarthritis were undertaken separately and at different timepoints. n=number of patients responding. N=number of patients in this group.
TNF=tumour necrosis factor. CRP=C-reactive protein. *Target population according to the approval status for anti-TNF drugs in non-radiographic axial spondyloarthritis in
the European Union and some other countries: patients with non-radiographic axial spondyloarthritis with raised CRP, or active sacroiliitis on MRI, or both. †Approximate
response rates calculated on the basis of the information obtained from the cited sources.

Table: ASAS40 response to biologicals in phase 3 clinical trials in patients with axial spondyloarthritis

(figure 5). Presence of positive CRP or MRI inflammation Other biological disease modifying antirheumatic drugs
is not mandatory for the treatment of ankylosing Anakinra, an interleukin-1 receptor antagonist, and
spondylitis, although those patients do also respond abatacept, a T-cell modulator, were tested in small
better than patients negative for these indices.119 If the prospective open-label trials89,90 in patients with
treatment results between ankylosing spondylitis and ankylosing spondylitis and did not have a better effect
non-radiographic spondyloarthritis are compared for than an expected (historical) placebo response. A similar
those patients who are treated according to the label in prospective open-label study127,128 with rituximab, a
the EU, the results are similar (table).120 For patients with monoclonal antibody directed against CD20 on B cells,
axial spondyloarthritis, raised CRP, short symptom produced inconclusive results. Tocilizumab129 and
duration (or young age), and active MRI inflammation sarilumab,130 both monoclonal antibodies directed
seem to be the best predictors for a good response to against the interleukin-6 receptor, were tested in two
TNF blockers.120 placebo-controlled double-blind studies in anti-TNF-
Discontinuation of TNF blocker in patients with axial naive patients with active ankylosing spondylitis, with
spondyloarthritis who had had a good response generally no efficacy compared with placebo.
resulted in a relapse in 75–90% of cases,121–123 without any By contrast, treatments targeting the interleukin-23–
major differences if NSAID therapy was continued or interleukin-17 axis seem to be very promising in patients
not,124 but a reduction of the TNF-blocker dose in good with axial spondyloarthritis. Until now, all completed
responders was tolerated by 52–86% of patients.125,126 studies of these treatments have been done in patients
However, these results are based on small numbers of with ankylosing spondylitis, but studies including those
patients and this question should be further examined in with non-radiographic axial spondyloarthritis are
larger trials. ongoing. In two phase 3 trials, the anti-interleukin-17

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 Seminar

interleukin-12 and interleukin-23) has been undertaken

Diagnosis* Ankylosing spondylitis Non-radiographic axial spondyloarthritis in patients with ankylosing spondylitis showing good
efficacy. This efficacy is being assessed further in
ongoing placebo-controlled trials in ankylosing
spondylitis and non-radiographic axial spondyloarthritis.
The oral Janus kinase inhibitor tofacitinib has been
tested in one phase 2 double-blind placebo-controlled
dose-ranging study134 in patients with ankylosing
spondylitis, providing a positive signal for a good
clinical and MRI response that needs confirmation in a
Failure of the At least 2 NSAIDs given for At least 2 NSAIDs given for larger trial. Apremilast, an oral PDE4 inhibitor, was
previous treatment 4 weeks in total 4 weeks in total tested in a small proof of concept trial135 in active
patients with ankylosing spondylitis for 12 weeks either
High disease activity BASDAI ≥4 or ASDAS ≥2·1† BASDAI ≥4 or ASDAS ≥2·1† with apremilast or placebo showing a moderate
and reduction of the disease activity but a larger
Objective signs of inflammatory activity: placebo-controlled phase 2 trial136 in patients with
ankylosing spondylitis did not show a response superior
to placebo treatment.
or CRP+
Treatment options for inhibition of radiographic
Active sacroiliitis progression
Possible treatments to stop radiographic progression
Figure 5: Current approval status for TNF-blocker treatment of axial spondyloarthritis patients in the involve early suppression of inflammation and targeting
European Union of molecules stimulating bone formation. TNF-blocker
No current approval for non-radographic axial spondyloarthritis in the USA; approval also in many other parts of treatment does not have an effect on radiographic
the world, but note that in some non-European Union countries the presence of objective signs of inflammation is
not mandatory. TNF=tumour necrosis factor. NSAIDs=non-steroidal anti-inflammatory drugs. ASDAS=Ankylosing
progression over 2 or 4 years of treatment in patients
Spondylitis Disease Activity Score. CRP=C-reactive protein. BASDAI=Bath Ankylosing Spondylitis Disease Activity with established longstanding ankylosing spondylitis.137,138
Index. *Based on a combination of clinical, laboratory, and imaging parameters. †According to the ASAS/EULAR But evidence shows that early treatment139 and treatment
recommendations.89 for more than 4 years140 might affect radiographic
inhibitor secukinumab was effective in patients with progression by suppression of inflammation and the
ankylosing spondylitis,114 and—on the basis of the results avoidance of subchondral granulation tissue.54 Direct
of these trials—have now been approved for ankylosing targeting of new bone formation might be associated
spondylitis in the EU, USA, and other parts of the world with too many side-effects affecting the general bone
(table). The positive treatment response was maintained metabolism. Biomarkers that predict new bone formation
throughout 52 weeks of treatment in both studies. A are needed to identify patients who would benefit from
dose of 300 mg secukinumab, which is more effective such treatments.
than 150 mg for the treatment of psoriasis, has not yet An inhibitory effect of contiuous NSAID therapy for
been investigated for ankylosing spondylitis. Although 2 years was reported in patients with ankylosing
no head-to-head trials have been done so far, the spondylitis in one randomised prospective trial.141 This
demonstrated effectiveness of secukinumab seems to be effect was backed by additional data from a retrospective
close to the response rates seen in TNF-blocker trials analysis,142 and from a prospective observational
undertaken in a similar patient group. Secukinumab spondyloarthritis cohort.143 A direct inhibitory effect of
was also effective in a subgroup of patients in whom NSAIDs on osteoblasts, mediated by prostaglandin
TNF-blocker therapy failed or was discontinued for inhibition, was postulated as a possible mechanism to
other reasons.131 explain these results. However, these findings could not
Nevertheless, the place of interleukin-17 inhibitors in be confirmed by another randomised prospective trial.144
the treatment of axial spondyloarthritis remains to be In the trial by Sieper and colleagues,144 most patients
determined as larger clinical experience grows. The were treated with diclofenac, whereas in the trial by
efficacy of secukinumab treatment in patients who failed Wanders and colleagues,141 most were given celecoxib.
to respond to a first TNF blocker needs to be compared Thus it is unclear whether the inhibitory effect was
with the effectiveness of treatment with a second TNF COX-2-specific (or even celecoxib-specific effect) in the
blocker. Additionally, whether interleukin-17 blockade trial by Wanders and colleagues141 or whether NSAIDs
might reduce the progression of new bone formation, as are just not effective for the inhibiton of new bone
was speculated on the basis of the results of one formation. Until additonal data become available,
uncontrolled ankylosing spondylitis trial,132 is unknown. NSAID treatment is only recommended for the
One prospective open-label trial133 of ustekinumab treatment of signs and symptoms but not to inhibit
(a monoclonal antibody against the p40 subunit of syndesmophyte growth.89,90

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