This year’s EULAR in the beautiful city of Madrid was “hot” indeed! And not only relating to the high temperatures but to some of the data presented. The main updates in axSpA referred to confirmatory data on radiographic progression and the concept of treat-to-target. Here are some, but by no means all abstracts that BRITSpA found interesting:
Five year data from 416 patients from the DESIR cohort confirmed previous observations from smaller trials, showing that between 15% of patients with axSpA already fulfil New York criteria within the first 2 to 3 years from disease presentation. However radiographic progressions is very slow during this time, suggesting that the division between radiographic and non-radiographic disease is not useful in the early stages of disease. As shown before, a higher prevalence of radiographic progressions is seen in those with objective signs of inflammation; ie: a positive MRI of the sacroiliac (SI) joint and a raised C-reactive protein (CRP). Reference: Dougados M et al. EULAR 2017. Abstract OP0116.
Data from a large registry in Switzerland explored which factors have an impact on radiographic progression in patients with ankylosing spondylitis, showing that those cases that had used TNF blockers for 4 years prior to the next radiograph, had a lower chance of progression when compared to those patients who had not taken TNF blockers. The authors concluded that TNFi seem to reduce radiographic progression in patients with AS and this effect is mediated at least in part, by a decrease in disease activity. Reference: Molnar C et al. EULAR 2017. Abstract OP0189.
In fact, these results were confirmed by another study looking at 409 patients with axSpA, both radiographic and non-radiographic, treated with certolizumab for four years. This study demonstrated that between weeks 96 to 204, there was very little radiographic progression. Most of the progression occurred earlier in the 0- to 96-week timeframe. Reference: van der Heijde D et al. EULAR 2017. Abstract OP0023.
Lastly, a study from Berlin reporting on the GESPIC cohort used the mSASSS to look at the association between radiographic sacroiliitis and parameters of functional status and spinal mobility such as BASFI and BASMI in 210 patients with axSpA, confirming that radiographic damage in the sacroiliac joint might also have an impact, although small, on spinal mobility and physical function in axSpA independently of structural damage in the spine and disease activity. Reference: Protopopov M et al. EULAR 2017. Abstract OP0118
A whole session was dedicated to Treat-to-target in axSpA: reality or utopy? This included the new update of the treat-to-target recommendations by D van der Heijde. Speakers touched upon the published data from the OASIS cohort [Ramiro S et al. Ann Rheum Dis. 2014;73:1455-1461], which clearly showed that there was an almost linear relationship between the level of disease activity (as measured by ASDAS) and the degree of radiographic change.
Discussions centered around whether the target should be clinical remission or inactive disease of musculoskeletal and, if possible, extra-articular manifestations, and suggestions that these targets should be individualised. The treatment modality needs to be considered when defining the time required to reach the target.
ASDAS is the preferred measure and target in axSpA as it is data-driven with clear, validated cut-offs, although BASDAI remains most frequently used in clinical practice. The frequency of the measurements depends on the level of disease activity. Other important points within the updated recommendations highlight the need to take co-morbidities, such as cardiovascular risk, into account.
M Dougados reflected on the challenges for applying treat-to-target in axSpA such as the need to engage the patient in shared decision-making and the need to adapt/increase the treatment in case the target is not reached after one or several treatment modalities.
References: Smolen JS et al. Ann Rheum Dis. 2017 Jul 6. pii: annrheumdis-2017-211734. doi:10.1136/annrheumdis-2017-211734. [Epub ahead of print]; Van der Heijde D et al. EULAR 2017, SP0056; Dougados M; EULAR 2017; SP0055
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