In terms of radiographic progression, about 20% of patients with nr-axSpA will show progression over five years. Thus, since the majority of patients do not experience progression, the question is: Do we need to treat all patients with nr-axSpA?
Dr. Ogdie-Beatty stated that it may be helpful to think about which patients are at highest risk of progression. This would include patients who are HLA-B27 positive; have elevated CRP; have imaging findings with low-grade, radiographic changes or MRI changes at baseline; have a history of smoking; and have a history of uveitis.
Progression in patients is slow, thus in some patients it may be worth discussing initial treatment with non-steroidal anti-inflammatory drugs (NSAIDs); if symptoms become more significant, discussion of biologic therapy would be warranted.
Treatment
Generally speaking, the treatment of radiographic and nr-axSpA is the same, and in both sets of patients, NSAIDs and corticosteroid injections would be potential options.
A significant oversight in the care of many patients with axial disease is the failure to prescribe physical therapy (PT). A great deal of pain can be attributed to mechanical symptoms and will improve with PT. Dr. Ogdie-Beatty routinely recommends exercise, stretching and core strengthening for her patients.
She also highly encourages patients to quit smoking if they are smokers.
In terms of biologic treatment, options include TNFα inhibitor, IL-17 inhibitor and Janus kinase (JAK) inhibitor therapy. These classes of biologics are regarded as similar in efficacy, although selection of therapy may depend on other variables, such as using a TNFα inhibitor in patients with a history of uveitis or inflammatory bowel disease. In terms of preventing radiographic progression, this is hard to demonstrate in studies because progression is slow and most trials may not have sufficient follow-up periods to evaluate this outcome.
In terms of treat-to-target strategies, Dr. Ogdie-Beatty advises that patients and providers work together to select an objective outcome to follow at each visit. For example, outcomes that may be meaningful to patients include the ability to work out at the gym or to have a successful pregnancy.
Even in patients with confirmed axial spondyloarthritis, not all back pain can or should be attributed to this condition. Patients with nr-axSpA may experience a disc herniation or other mechanical causes of back pain.
In addition, about 30% of patients with axSpA have fibromyalgia, and thus, management of such comorbidities is essential.
