Tailor Ankylosing Spondylitis Therapy to Patient's Priorities

FORT LAUDERDALE, FLA. — The treatment of ankylosing spondylitis should include both pharmacologic and nonpharmacologic modalities tailored to the current manifestations of the disease, and should reflect the wishes and expectations of the patient, according to Dr. Tore K. Kvien.

All domains of health status are affected by the disease, from bodily pain to social functioning, according to findings from a survey of patients with ankylosing spondylitis (AS). Interrupted sleep was the most frequently reported problem, surpassing difficulties in climbing stairs and getting out of bed.

“A way of addressing the complexity of this disease and prioritizing our treatment is by asking not only how the patient feels and is doing, but also asking about their priorities in treatment and what issues are most important to them,” said Dr. Kvien, professor of rheumatology, University of Oslo, and past president of EULAR as well as editor of the Annals of the Rheumatic Diseases.

“The optimal management of AS requires a combination of nonpharmacologic and pharmacologic modalities, with nonpharmacologic strategies possibly being more important than in many of the other diseases we treat,” Dr. Kvien said at a meeting sponsored by RHEUMATOLOGY NEWS and Skin Disease Education Foundation.

Exercise is crucial for these patients and is most beneficial in a formalized program. An updated Cochrane review of physiotherapy in AS recently concluded that individual home-based exercise is better than no exercise, that supervised group physiotherapy is preferable to home exercise, and that pool exercise followed by group physiotherapy is better than group exercise alone (Cochrane Database Syst. Rev. 2008 Jan. 23;CD002822).

The most effective medical treatments in AS differ from those for rheumatoid arthritis (RA), clinicians have learned. For example, the Assessment in Ankylosing Spondylitis International Working Group recommends nonsteroidal anti-inflammatory drugs as first-line treatment for pain and stiffness, and, as such, NSAIDs represent a more prominent component of treatment in AS than in RA. Corticosteroid injections also are recommended, but evidence does not support the use of systemic steroids for axial disease, said Dr. Kvien, also head of rheumatology, Diakonhjemmet Hospital, Oslo.

Conventional disease-modifying antirheumatic drugs (DMARDs) play a less prominent role in AS, with evidence of their efficacy being much weaker than in RA. Some recent studies, however, have suggested that sulfasalazine or methotrexate may be useful for patients with peripheral arthritis, Dr. Kvien said.

A further difference in treatment strategy compared with RA is that there is no requirement for a prior trial of DMARDs before initiating anti-tumor necrosis factor (TNF) therapy in the patient with a persistently high level of AS disease activity. There also is no evidence that combination therapy with a TNF inhibitor and a DMARD is better than the biologic alone.

All three of the available TNF inhibitors have demonstrated efficacy, and there has been no suggestion from the clinical trials that there are any differences in efficacy among them. One special circumstance is for the patient with acute anterior uveitis, however. “Some data suggest that in a patient with ongoing uveitis, the antibodies [infliximab and adalimumab] may be more effective than etanercept, but if the patient just has a history of one attack, you can use whatever you like,” Dr. Kvien said. The same general safety concerns exist for the use of these drugs in AS as in RA, he added.

Increasing experience with TNF inhibitors in AS also has shown that they are associated with greater improvements in health-related quality of life than in RA. “Our data from observational studies have shown that the improvements on all dimensions of the [Short Form Health Survey] SF-36 were greater in patients with AS than in those with RA,” he said. Differences were most notable on scores for emotional role, physical functioning, physical role, and vitality (Arthritis Rheum. 2005;52:2506–12).

Drug retention rates for the TNF inhibitors also are better for AS than for either RA or psoriatic arthritis, said Dr. Kvien. In another observational study, unadjusted 1-year retention rates were 77.5%, 77.3%, and 65.4%, in the AS, psoriatic arthritis, and RA groups, respectively, while adjusted hazard ratios for treatment termination were 0.76 for psoriatic arthritis versus RA and 0.66 for AS versus RA (Arthritis Rheum. 2008;59:234–40).

Dr. Kvien disclosed that he receives grant research support from, and acts as a consultant to, several companies, including Abbott Laboratories, Hoffmann-La Roche Inc., and Wyeth.

SDEF and this news organization are owned by Elsevier.

FORT LAUDERDALE, FLA. — The treatment of ankylosing spondylitis should include both pharmacologic and nonpharmacologic modalities tailored to the current manifestations of the disease, and should reflect the wishes and expectations of the patient, according to Dr. Tore K. Kvien.

All domains of health status are affected by the disease, from bodily pain to social functioning, according to findings from a survey of patients with ankylosing spondylitis (AS). Interrupted sleep was the most frequently reported problem, surpassing difficulties in climbing stairs and getting out of bed.

“A way of addressing the complexity of this disease and prioritizing our treatment is by asking not only how the patient feels and is doing, but also asking about their priorities in treatment and what issues are most important to them,” said Dr. Kvien, professor of rheumatology, University of Oslo, and past president of EULAR as well as editor of the Annals of the Rheumatic Diseases.

“The optimal management of AS requires a combination of nonpharmacologic and pharmacologic modalities, with nonpharmacologic strategies possibly being more important than in many of the other diseases we treat,” Dr. Kvien said at a meeting sponsored by RHEUMATOLOGY NEWS and Skin Disease Education Foundation.

Exercise is crucial for these patients and is most beneficial in a formalized program. An updated Cochrane review of physiotherapy in AS recently concluded that individual home-based exercise is better than no exercise, that supervised group physiotherapy is preferable to home exercise, and that pool exercise followed by group physiotherapy is better than group exercise alone (Cochrane Database Syst. Rev. 2008 Jan. 23;CD002822).

The most effective medical treatments in AS differ from those for rheumatoid arthritis (RA), clinicians have learned. For example, the Assessment in Ankylosing Spondylitis International Working Group recommends nonsteroidal anti-inflammatory drugs as first-line treatment for pain and stiffness, and, as such, NSAIDs represent a more prominent component of treatment in AS than in RA. Corticosteroid injections also are recommended, but evidence does not support the use of systemic steroids for axial disease, said Dr. Kvien, also head of rheumatology, Diakonhjemmet Hospital, Oslo.

Conventional disease-modifying antirheumatic drugs (DMARDs) play a less prominent role in AS, with evidence of their efficacy being much weaker than in RA. Some recent studies, however, have suggested that sulfasalazine or methotrexate may be useful for patients with peripheral arthritis, Dr. Kvien said.

A further difference in treatment strategy compared with RA is that there is no requirement for a prior trial of DMARDs before initiating anti-tumor necrosis factor (TNF) therapy in the patient with a persistently high level of AS disease activity. There also is no evidence that combination therapy with a TNF inhibitor and a DMARD is better than the biologic alone.

All three of the available TNF inhibitors have demonstrated efficacy, and there has been no suggestion from the clinical trials that there are any differences in efficacy among them. One special circumstance is for the patient with acute anterior uveitis, however. “Some data suggest that in a patient with ongoing uveitis, the antibodies [infliximab and adalimumab] may be more effective than etanercept, but if the patient just has a history of one attack, you can use whatever you like,” Dr. Kvien said. The same general safety concerns exist for the use of these drugs in AS as in RA, he added.

Increasing experience with TNF inhibitors in AS also has shown that they are associated with greater improvements in health-related quality of life than in RA. “Our data from observational studies have shown that the improvements on all dimensions of the [Short Form Health Survey] SF-36 were greater in patients with AS than in those with RA,” he said. Differences were most notable on scores for emotional role, physical functioning, physical role, and vitality (Arthritis Rheum. 2005;52:2506–12).

Drug retention rates for the TNF inhibitors also are better for AS than for either RA or psoriatic arthritis, said Dr. Kvien. In another observational study, unadjusted 1-year retention rates were 77.5%, 77.3%, and 65.4%, in the AS, psoriatic arthritis, and RA groups, respectively, while adjusted hazard ratios for treatment termination were 0.76 for psoriatic arthritis versus RA and 0.66 for AS versus RA (Arthritis Rheum. 2008;59:234–40).

Dr. Kvien disclosed that he receives grant research support from, and acts as a consultant to, several companies, including Abbott Laboratories, Hoffmann-La Roche Inc., and Wyeth.

SDEF and this news organization are owned by Elsevier.

FORT LAUDERDALE, FLA. — The treatment of ankylosing spondylitis should include both pharmacologic and nonpharmacologic modalities tailored to the current manifestations of the disease, and should reflect the wishes and expectations of the patient, according to Dr. Tore K. Kvien.

All domains of health status are affected by the disease, from bodily pain to social functioning, according to findings from a survey of patients with ankylosing spondylitis (AS). Interrupted sleep was the most frequently reported problem, surpassing difficulties in climbing stairs and getting out of bed.

“A way of addressing the complexity of this disease and prioritizing our treatment is by asking not only how the patient feels and is doing, but also asking about their priorities in treatment and what issues are most important to them,” said Dr. Kvien, professor of rheumatology, University of Oslo, and past president of EULAR as well as editor of the Annals of the Rheumatic Diseases.

“The optimal management of AS requires a combination of nonpharmacologic and pharmacologic modalities, with nonpharmacologic strategies possibly being more important than in many of the other diseases we treat,” Dr. Kvien said at a meeting sponsored by RHEUMATOLOGY NEWS and Skin Disease Education Foundation.

Exercise is crucial for these patients and is most beneficial in a formalized program. An updated Cochrane review of physiotherapy in AS recently concluded that individual home-based exercise is better than no exercise, that supervised group physiotherapy is preferable to home exercise, and that pool exercise followed by group physiotherapy is better than group exercise alone (Cochrane Database Syst. Rev. 2008 Jan. 23;CD002822).

The most effective medical treatments in AS differ from those for rheumatoid arthritis (RA), clinicians have learned. For example, the Assessment in Ankylosing Spondylitis International Working Group recommends nonsteroidal anti-inflammatory drugs as first-line treatment for pain and stiffness, and, as such, NSAIDs represent a more prominent component of treatment in AS than in RA. Corticosteroid injections also are recommended, but evidence does not support the use of systemic steroids for axial disease, said Dr. Kvien, also head of rheumatology, Diakonhjemmet Hospital, Oslo.

Conventional disease-modifying antirheumatic drugs (DMARDs) play a less prominent role in AS, with evidence of their efficacy being much weaker than in RA. Some recent studies, however, have suggested that sulfasalazine or methotrexate may be useful for patients with peripheral arthritis, Dr. Kvien said.

A further difference in treatment strategy compared with RA is that there is no requirement for a prior trial of DMARDs before initiating anti-tumor necrosis factor (TNF) therapy in the patient with a persistently high level of AS disease activity. There also is no evidence that combination therapy with a TNF inhibitor and a DMARD is better than the biologic alone.

All three of the available TNF inhibitors have demonstrated efficacy, and there has been no suggestion from the clinical trials that there are any differences in efficacy among them. One special circumstance is for the patient with acute anterior uveitis, however. “Some data suggest that in a patient with ongoing uveitis, the antibodies [infliximab and adalimumab] may be more effective than etanercept, but if the patient just has a history of one attack, you can use whatever you like,” Dr. Kvien said. The same general safety concerns exist for the use of these drugs in AS as in RA, he added.

Increasing experience with TNF inhibitors in AS also has shown that they are associated with greater improvements in health-related quality of life than in RA. “Our data from observational studies have shown that the improvements on all dimensions of the [Short Form Health Survey] SF-36 were greater in patients with AS than in those with RA,” he said. Differences were most notable on scores for emotional role, physical functioning, physical role, and vitality (Arthritis Rheum. 2005;52:2506–12).

Drug retention rates for the TNF inhibitors also are better for AS than for either RA or psoriatic arthritis, said Dr. Kvien. In another observational study, unadjusted 1-year retention rates were 77.5%, 77.3%, and 65.4%, in the AS, psoriatic arthritis, and RA groups, respectively, while adjusted hazard ratios for treatment termination were 0.76 for psoriatic arthritis versus RA and 0.66 for AS versus RA (Arthritis Rheum. 2008;59:234–40).

Dr. Kvien disclosed that he receives grant research support from, and acts as a consultant to, several companies, including Abbott Laboratories, Hoffmann-La Roche Inc., and Wyeth.

SDEF and this news organization are owned by Elsevier.