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Benefits and Shortcomings of Anti-Tumour Necrosis Factor Drugs in Spondyloarthritis

Infliximab and etanercept, anti-tumour necrosis factor drugs, are highly effective in the treatment of ankylosing spondylitis and psoriatic arthritis, yet their long-term effects still require further study.

Effective treatments for spondyloarthritis are severely lacking as compared to those for rheumatoid arthritis (RA). Currently, there are no effective long-term therapies for severely affected spondyloarthritis patients, specifically for those with ankylosing spondylitis, the most frequent and severe form of spondyloarthritis.

The anti-tumour necrosis factor agents have emerged as an effective treatment option for patients with RA but these agents may also be effective in treating other forms of arthritis, including spondyloarthritis.

Juergen Braun, MD, and colleagues at the Hospital Benjamin Franklin, Free University, Berlin, Germany, reviewed the benefits and pitfalls of anti-tumour necrosis factor therapy in patients with spondyloarthritis.

Current available anti-tumour necrosis factor agents approved for treatment of RA in the United States and Europe include infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira). A growing number of studies have now determined that infliximab (5 mg/kg every 6 to 12 weeks) and etanercept (25 mg subcutaneous injection twice a week) are also highly effective in the short term treatment of spondyloarthritis.

These studies looked specifically at treatment in patients with ankylosing spondylitis and psoriatic arthritis, although preliminary evidence also suggests their effectiveness in undifferentiated spondyloarthritis. Furthermore, it appears that their effectiveness in spondyloarthritis is greater than that observed in RA.

Based on these findings, infliximab has recently been approved for ankylosing spondylitis in Europe and etanercept has been approved for psoriatic arthritis.

Although severe adverse events are rare, reports have included sepsis and tuberculosis, lymphoma, anaemia and pancytopaenia, demyelinating disorders and neuropathy, exacerbations of congestive heart failure, and the occurrence of autoantibodies and autoimmunity. Dr. Braun notes that appropriate patient screening will likely aid in the prevention of such events.

Despite the obvious benefits of anti-necrosis factor therapy, many issues still require further investigation, including its long-term safety and efficacy; the ability of these agents to prevent progression of ankylosis; the most effective dosage and interval for treatment; the need for autoantibody screening; and the effects of supplementing disease modifying anti-rheumatic drugs (DMARDs) and tuberculosis prophylaxis.

Dr. Braun concludes that "anti-TNF therapy seems to be a powerful tool for the treatment of ankylosing spondylitis and other types of spondyloarthritis." He adds that "tumour necrosis factor blockers may even be considered a first-line treatment in a patient with active ankylosing spondylitis and psoriatic arthritis whose condition is not sufficiently controlled with [more traditional therapies]."
Curr Opin Rheumatol 2003 Jul;15:4:394-407. "Biologic therapies in the spondyloarthritis: new opportunities, new challenges"

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