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EULAR has very clinical sessions called How to Treat (HOT). On the menu today was AS/axial SpA presented by Dr Filip Van den Bosch from Belgium who did an outstanding job. It was packed full of information, some of which was not new to us so I will hit the pearls in point form below.
1. The last EULAR guidelines from 2010 are already outdated. Luckily, the updated guidelines are being presented this Saturday. Stay tuned for that.
2. Make the right diagnosis. There is a spectrum of axial disease and it is very heterogeneous. Avoid what he called "B27 -itis" and "MRI-itis" when your clinical judgement tells you it is mechanical pain.
3. Treat the right patients aggressively. Studies show that high disease activity leads to more structural damage and increased mortality.
4. NSAIDs still have a role to play. In diagnosis, if the patient has 0 response, you may be dealing with mechanical back pain. INFAST showed that 1/3 of patients taking full dose naproxen were in remission after 6 months. Patients with high CRP may be the best candidates for continuous NSAIDs. Regarding toxicity, Haroon et al showed decreased CV risk with NSAIDs in AS.
5. Certolizumab's Phase 3 trial was the first to show no difference in response between radiographic and non-radiographic axial SpA with patients selected for objective signs of inflammation.
6. Biologics have revolutionized treatment. Effective options are now TNFi and secukinumab. Ustekimumab trials are ongoing but preliminarily it looks good. Ineffective treatments include IL-6, ABT and sarilumab.
7. Evidence for prevention of structural damage is still lacking. His personal opinion is to treat early to see an effect.
8. Treat to target studies are coming. TICOSPA: tight control in SpA is ongoing.
9. Can we ever stop therapy completely? He felt no based on the data we have now. Can we taper to a lower dose or interval? Yes for some patients.
10. Finally, since we have unanswered questions in this field, we are still working on the premise of "experts" opinion (plural); the clinical expertise of the doctor and the patient's expertise of living with the disease.
Well done Dr Van den Bosch!
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About the Author
Dr. Shelly Dunne
Dr. Shelley Dunne is a graduate of Memorial University of Newfoundland School of Medicine. She completed her training in Internal Medicine and a fellowship in Rheumatology at the University of Toronto. She has been in private practice since 1998 and is currently a consulting rheumatologist at the Toronto East General Hospital.
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