“They work; they can actually help you distinguish mechanical from inflammatory back pain,” he said. “But you have to take into account that someone who is really a primary non-responder should be critically reevaluated.” Such patients could have been incorrectly diagnosed, he said.
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Evidence shows that a young patient with high disease activity but low functional trouble and who has objective signs of inflammation is the ideal candidate to respond to anti-TNF treatment. The opposite also seems to be true: the older the patient without objective signs of inflammation, the greater the chances of treatment discontinuation, he noted.8
Other research has shown which patients tend to have a better chance of having a major response when an anti-TNF is added as opposed to continuing on NSAIDs. Those with low function, high inflammation, age below 40 and who are HLA-B27 positive tend to be the best candidates.9 Dr. van den Bosch cautioned clinicians not to “become a computer” but only to use such information as a guide.
He is now working on a trial looking at the value of tight control in spondyloarthritis. Real-life outcomes—not disease-activity scores—should be the guide, he said.
“It doesn’t make sense to say, ‘I’m going to treat you more intensively if your ASDAS is above a certain point,’ and then the endpoint of your trial is, ‘Well, I have more patients with an ASDAS below that point,’” he said. “I think you have to look at other endpoints—ideally structural damage, quality of life, getting back to work.”
Thomas R. Collins is a freelance medical writer based in Florida.
- Krishnadas R, Nicol A, Sassarini J, et al. Circulating tumour necrosis factor is highly correlated with brainstem serotonin transporter availability in humans. Brain Behav Immun. 2016 Jan;51:29–38.
- Mease PJ, Heckaman M, Kary S, et al. Application and modifications of minimal disease activity measures for patients with psoriatic arthritis treated with adalimumab: Subanalyses of ADEPT. J Rheumatol. 2013 May;40(5):647–652.
- McInnes IB, Kavanaugh A, Gottlieb AB, et al. Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet. 2013 Aug 31;382(9894):780–789.
- McInnes IB, Mease PJ, Kirkham B, et al. Secukinumab, a human anti-interleukin-17A monoclonal antibody, in patients with psoriatic arthritis (FUTURE 2): A randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2015 Sep 19;386(9999):1137–1146.
- Ramiro S, van der Heijde D, van Tubergen A, et al. Higher disease activity leads to more structural damage in the spine in ankylosing spondylitis: 12-year longitudinal data from the OASIS cohort. Ann Rheum Dis. 2014 Aug;73(8):1455–1461.
- Baeten D, Sieper J, Braun J, et al. Secukinumab, an Interleukin-17A inhibitor, in ankylosing spondylitis. N Engl J Med. 2015 Dec 24;373(26):2534–2548.
- Landewe R, Braun J, Deodhar A, et al. Efficacy of certolizumab pegol on signs and symptoms of axial spondyloarthritis including ankylosing spondylitis: 24-week results of a double-blind randomised placebo-controlled Phase 3 study. Ann Rheum Dis. 2014 Jan;73(1):39–47.
- Arends S, Brouwer E, van der Veer E, et al. Baseline predictors of response and discontinuation of tumor necrosis factor-alpha blocking therapy in ankylosing spondylitis: A prospective longitudinal observational cohort study. Arthritis Res Ther. 2011 Jun 20;13(3):R94.
- Vastesaeger N, van der Heijde D, Inman RD, et al. Predicting the outcome of ankylosing spondylitis therapy. Ann Rheum Dis. 2011 Jun;70(6):973–981.