Rheumatology 2003; 42: 490
© 2003 British Society for Rheumatology
Letters to the Editor |
Anti-tumour necrosis factor therapy in ankylosing spondylitis. A need for guidelines
Department of Rheumatology, Dudley Group of Hospitals NHS Trust, Dudley, West Midlands, DY1 4S, UK and
1 4th Department of Internal Medicine, Hippocratio Hospital, Medical School University of Thessaloniki, Greece
SIR, Several investigators have recently reported significant clinical and serological improvement in patients with ankylosing spondylitis (AS) treated with the anti-tumour necrosis factor (TNF) agents infliximab [1–3] or etanercept [4].
Although this is a very promising development, there are practical considerations that need to be taken into account in the everyday use of these agents in AS. The involvement of TNF in the pathology of AS is not as clear as in rheumatoid arthritis (RA); concrete evidence of long-term benefit is currently lacking, particularly prevention of ankylosis, and there are no markers to identify patients who will respond to treatment. More studies are needed to establish these; otherwise the use of anti-TNFs in AS may be as rather expensive anti-inflammatories with no real disease-modifying action.
We propose that the rheumatological community should agree eligibility criteria for the use of anti-TNFs in two groups of patients with AS: those with only spinal involvement and those with spinal, peripheral or extra-articular involvements, and establish a patient register, as it has already done for RA [5].
Failure of two disease-modifying drugs to control peripheral joint or hip involvement, insufficient symptomatic response to non-steroidal anti-inflammatory drugs including phenylbutazone [6], inflammatory eye disease [7], and Bath AS disease activity index (BASDAI) of 
4 would probably be reasonable eligibility criteria.
In AS, it is likely that many young males may need to be treated with anti-TNF agents, so their effects on spermatogenesis should be addressed at an early stage.
G. Kitas is involved in clinical trials of anti-TNF agents in rheumatoid arthritis. D. G. Kassimos is on study leave from the Ministry of Defence of Greece.
Notes
Correspondence to: D. G. Kassimos. E-mail: D.Kassimos{at}dudleygoh-tr.wmids.nhs.uk 
References
- Hadi A, Hickling P, Brown M, Al-Nahhas A. Scintigraphic evidence of effect of infliximab on disease activity in ankylosing spondylitis. Rheumatology 2002;41:114–6.[Medline]
- Braun J, Brandt J, Listing J et al. Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial. Lancet 2002;359:1187–93.[CrossRef][ISI][Medline]
- Maksymowych WP, JHangri GS, Lambert RG et al. Infliximab in ankylosing spondylitis: A prospective observational inception cohort analysis of efficacy and safety. J Rheumatol 2002;29:959–65.[ISI][Medline]
- Gorman JD, Sack KE, Davis JC Jr. Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor
. N Engl J Med 2002;346:1349–56.[Abstract/Free Full Text] - Report of the Working Party of the British Society for Rheumatology. April 2000.
- Brophy S, Mackay K, Al-Saidi A, Taylor G, Calin A. The natural history of ankylosing spondylitis as defined by radiological progression. J Rheumatol 2002;29:1236–43.[Medline]
- Smith JR, Levinson RD, Holland GN et al. Differential efficacy of tumor necrosis factor inhibition in the management of inflammatory eye disease and associated rheumatic disease. Arthritis Care Res 2001;45:252–7.[CrossRef][ISI][Medline]
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