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Rheumatology Advance Access originally published online on June 26, 2009
Rheumatology 2009 48(9):1029-1035; doi:10.1093/rheumatology/kep146
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© The Author 2009. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Reviews

Treatment of ankylosing spondylitis and extra-articular manifestations in everyday rheumatology practice

Dirk Elewaut1 and Marco Matucci-Cerinic2

1Department of Rheumatology, Ghent University Hospital, Ghent, Belgium and 2Division of Rheumatology, University of Florence, Florence, Italy.

Correspondence to: Dirk Elewaut, Department of Rheumatology, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium. E-mail: dirk.elewaut{at}ugent.be


  Abstract

The SpAs are a group of overlapping, chronic, inflammatory rheumatic diseases including AS, a chronic inflammatory disease primarily affecting the SI joints. In addition to inflammatory back pain, AS patients are also more likely to experience extra-articular manifestations belonging to the SpA concept which can affect the eyes, the gastrointestinal tract and the skin and other related inflammatory conditions. This review focuses on current progress in treatment options in SpA with special emphasis on extra-articular features. TNF inhibition has demonstrated effectiveness in the treatment of AS symptoms and all currently available anti-TNF agents appear to have similar efficacy. However, the efficacy of anti-TNF agents varies in the treatment of extra-articular manifestations and comorbidities. Analyses of trials of anti-TNF agents in patients with AS have revealed significant reductions in the incidence of flares of uveitis and IBD with infliximab and adalimumab (uveitis only) treatment but not with etanercept. All three anti-TNF agents (infliximab, adalimumab, etanercept) have demonstrated efficacy in psoriasis (not associated with AS). When evaluating as to which agent to use in the treatment of AS, an important consideration is the overall well-being of the patient. This should include any additional inflammatory burden that manifests in other parts of the body, which may currently be subclinical. Based on current evidence, among TNF inhibitors, the monoclonal antibodies (infliximab and adalimumab) are more appropriate than etanercept if extra-articular manifestations or comorbid conditions are present or suspected. To date, infliximab appears to be the best studied agent with a wide spectrum of proven efficacy.

KEY WORDS: Ankylosing spondylitis, Extra-articular manifestation, Biologic therapy, Tumour necrosis factor-{alpha}, Quality of life

Submitted 2 February 2009; revised version accepted 11 May 2009.
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