How early should ankylosing spondylitis be treated with tumour necrosis factor blockers?

Abstract

Recognition and treatment of ankylosing spondylitis (AS) in the early stages of the disease has yet to be established. This paper considers the evidence available and the questions that need to be answered regarding the benefits of early diagnosis and treatment with tumour necrosis factor (TNF) blockers in AS. The authors conclude that AS can and has to be diagnosed earlier than is being done at present, before radiological changes are evident, and the potential of TNF blockers to induce long term remission if given early enough needs to be clarified.

Figure 1

There is a continuous spectrum in patients with axial spondyloarthritis (SpA) from a pre-radiological stage to a radiological stage (classic ankylosing spondylitis) of the disease. Reproduced with permission from Rudwaleit M, Khan MA, Sieper J. The challenge of diagnosis and classification in early ankylosing spondylitis: do we need new criteria? [review] Arthritis Rheum 2005;52:1000–8, New Jersey: John Wiley and Sons, Inc.

Figure 2

Patients with ankylosing spondylitis show a better response if treated with tumour necrosis factor blockers (infliximab or etanercept) early in the course their disease as judged by the percentage of patients showing a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) 50% improvement. Modified from Rudwaleit M, Listing J, Brandt J, Braun J, Sieper J. Prediction of a major clinical response (BASDAI 50) to tumour necrosis alpha blockers in ankylosing spondylitis. Ann Rheum Dis 2004;63:665–70.

Figure 3

(A–C) Magnetic resonance imaging (MRI) scan (STIR (short tau inversion recovery) technique) of the spine during treatment with infliximab (5 mg/kg body weight given every six weeks) showing disappearance of acute inflammation (anterior spondylitis).¹⁵