The Role of Early Treatment in the Management of Axial Spondyloarthritis: Challenges and Opportunities

Abstract

Axial spondyloarthritis (axSpA) is a chronic, inflammatory rheumatic disease that primarily affects the axial skeleton, often inflicting severe pain, diminished mobility, and a compromised quality of life. The advent of Assessment of SpondyloArthritis international Society (ASAS) classification criteria for spondyloarthritis (SpA) have enabled the classification of patients with axSpA in the non-radiographic stage but poorly perform if mistakenly used for diagnostic purposes. Despite notable progress in early diagnosis facilitated by referral strategies and extensive magnetic resonance imaging (MRI) utilization, diagnostic delays persist as a concerning issue. This underscores the urgency to narrow the diagnostic gap and highlights the critical role of early diagnosis in mitigating the long-term structural damage associated with this condition. Research into the impact of non-steroidal anti-inflammatory drugs (NSAIDs) and biologic disease-modifying antirheumatic drugs (bDMARDs) on inflammatory symptoms and radiographic progression has been extensive. A compelling body of evidence suggests that early intervention leads to superior disease outcomes. However, most of these studies have centered on patients with established diseases rather than those in the early stages. Consequently, findings from studies on early pharmacological intervention remain inconclusive, and the potential for modifying the disease trajectory is still debatable. Without precise data from clinical trials, insights from basic science regarding the pathogenic mechanisms might point toward potential targets that warrant early intervention in the disease process. This review underscores the urgency of early diagnosis and intervention in axSpA, highlighting ongoing research gaps and the need for further exploration to improve patient outcomes.

Keywords: Disease progression; Early axial spondyloarthritis; IL-17 pathway; TNF-alpha; Therapeutic intervention.

Fig. 1

MRI of sacroiliac joints of a 38-year-old male patient with inflammatory back pain for years, HLA-B27 positivity and elevated CRP. A STIR sequence shows subchondral bone marrow edema and a subchondral cyst or an erosion localized in the mid part of the joint (arrow). B T1-weighted sequence demonstrates erosions with fat metaplasia in the erosion cavity (backfill)—bold arrow, as well as a fat lesion (thin arrow) and sclerosis (dotted arrow). C The erosion-sensitive sequence (VIBE) confirms the presence of erosions (arrows). CRP C-reactive protein, MRI magnetic resonance imaging, STIR short tau inversion recovery, VIBE volumetric interpolated breath-hold examination. Poddubnyy D. Joint Bone Spine 2023 Jan;90(1):105,468. Published under a Creative Commons license (CC BY 4.0)

Fig. 2

The currently recommended MRI sequences the diagnostic evaluation of sacroiliac joints in patients with suspected axial spondyloarthritis. MRI magnetic resonance imaging, STIR short tau inversion recovery, VIBE volumetric interpolated breath-hold examination

Fig. 3

Pitfalls, opportunities, and challenges in the early treatment of AxSpA. ASAS Assessment of spondyloarthritis international society-spondyloarthritis, AxSpA axial Spondyloarthritis, bDMARD biologic disease-modifying antirheumatic drugs, IBD inflammatory bowel disease, NSAID non-steroidal anti-inflammatory drugs, tsDMARD targeted synthetic disease-modifying antirheumatic drug