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How is the choice for biologics different for Spondyloarthritis?

How is the choice for biologics different for Spondyloarthritis?

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By Dr Irwin Lim, Rheumatologist

Barry from Florida emailed me regarding the post on biologic choice for Rheumatoid Arthritis (link).

He's kindly agreed to let me quote him as I think it's informative to answer his questions in this public forum. He writes:

"I have ankylosing spondylitis and crohn's disease. After a dozen years of experimentation, I have found the following:

  1. Remicade is very effective for reducing crohn's related inflammation of my colon, but has no effect on my arthritis pain or stiffness.
  2. Enbrel is very effective for reducing my ankylosing spondylitis stiffness and pain, yet gives no benefit for intestinal inflammation / cramping.

Since I cannot be on two biologics at once, I've had to switch back and forth between them, depending on which condition was most debilitating at the time. This is, of course, a very slow process. It takes so long for one medication to completely leave my system, and so long for the other to build up in my system that this is nearly impractical to do............

.....I do believe that colitis or crohn's is not only the most common condition associated with many types of arthritis, it is also potentially one of the most deadly. Finding a biologic that is effective for both conditions is my challenge. I am trying Cimzia at the present time, to see if it is effective for both conditions. It took several months before I began to see a benefit, but it is improving my stiffness and pain now. I am sleeping better at night. But, it is difficult to establish it's effectiveness on crohn's until I go a very extended period without any type of flare up.....

....Do you have any advice or experience with biologics that are effective for both arthritis and crohn's?"

Barry doesn't have Rheumatoid Arthritis.

He has been diagnosed with Spondyloarthritis.

Spondyloarthritis (SpA) does not relate to one neat, specific disease entity. Instead, it is a term used to cover a group of rheumatic diseases that are characterised by common clinical features, most frequent of which is inflammatory back pain. Diseases belonging to this SpA group include:

  1. Ankylosing Spondylitis;
  2. Psoriatic Arthritis: usually the patient also has psoriasis, an autoimmune skin condition;
  3. Inflammatory Bowel Disease-related arthritis: associated with Crohn’s disease or Ulcerative Colitis;
  4. Reactive arthritis: when the condition is triggered by an infection, most commonly affecting the genito-urinary or intestinal tract;
  5. Patients who do not quite demonstrate sufficient features to meet the criteria for the above classifications, & are then described as having undifferentiated SpA or peripheral SpA or non-radiographic Axial SpA.

Please note that the above describes quite a varied group and depending on the primary manifestations, these patients when referred on for specialist care, may see a gastroenterologist, a dermatologist, an ophthalmologist or a rheumatologist. Types of initial treatment used will differ, and criteria will differ for consideration of biologic treatment.

I am now going to generalise.

If a patient has SpA, not responding to the standard treatments, and meets criteria for biologic DMARD treatment, the current choice of biologic is simple.

TNF-inhibitor.

In the post on biologic choice for Rheumatoid Arthritis, I mentioned Tocilizumab (an IL-6 inhibitor), Abatacept (inhibits co-stimulation of T-cells) and Rituximab (antibody against CD20, affecting B-cells). None of these are effective in SpA.

TNF-inhibitor medication is the class of biologic DMARD with good clinical trial evidence and approval for use in Ankylosing Spondylitis, in Psoriasis & Psoriatic Arthritis, in Crohn's Disease & Ulcerative Colitis. The TNF-inhibitor medications help the joint symptoms (both peripheral joint & spine), the skin manifestations, the eye disease, and the bowel symptoms.

And typically, they help the different manifestations in the same patient.

Unfortunately for Barry, this hasn't yet been the case. My response to Barry's email was along these lines:

Enbrel is Etanercept (-cept) and it has a slightly different mode of action. Etanercept does not seem useful for inflammatory bowel disease and is also a little less effective with psoriasis.

In general for patients with SpA, I use one of the -mab group of TNF inhibitors, for example, Infliximab (Remicade) or Adalimumab (Humira).

The -mab group of TNF inhibitors has been shown to be effective in treating inflammatory bowel disease and ankylosing spondylitis so this would seem the best choice for him.

While it's surprising that Infliximab was never effective for his ankylosing spondylitis, it would still make sense for Barry to swap to a different -mab, and he has, to Certolizumab (Cimzia). Hopefully, this will be the answer.

As always, I welcome your thoughts and any experiences you can share.

BJC Health established the Sydney Spondyloarthritis Centre in 2011. We raise the profile of these diseases, we provide a better pathway to diagnosis, provide education as well as world-class treatment. Most importantly, we care & we want to improve the lives of people suffering from these diseases. Read about it here.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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