title: Conventional DMARD therapy (methotrexate-sulphasalazine) may decrease the requirement of biologics in routine practice of ankylosing spondylitis patients: a real-life experience.
abstract: OBJECTIVE
  The effect of disease-modifying antirheumatic drugs (DMARDs) in ankylosing spondylitis (AS) is still controversial. We aimed to evaluate the efficacy of sulphasalazine (SSZ) mono- or combination therapy with methotrexate (MTX) in AS patients naive to anti-tumor necrosis factor alpha (TNFα) agents.
  
  
  METHODS
  Patients with AS (n = 87, male : female, 46 : 41) treated with SSZ (n = 61) or SSZ + MTX (n = 26) combination and a documented 6-month follow-up were evaluated retrospectively. Disease activity was assessed by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), C-reactive protein and erythrocyte sedimentation rate. Requirement for anti-TNFα therapy was assessed after 6 months.
  
  
  RESULTS
  Mean (SD) age was 43.0 (11.0) versus 40.2 (11.1) and disease duration was 11.0 (8.6) versus 8.2 (5.2) years, in the SSZ and SSZ + MTX groups, respectively. Initially, 59% (34/61) of the patients in SSZ monotherapy and 68% (17/26) in the combination arm had BASDAI > 4. At the end of the study, BASDAI scores decreased similarly in both groups (mono: 1.4 [-7-6] versus combination: 0.7 [-3-6] P = 0.2). BASDAI was > 4 in 32.8% (20/61) of patients in the SSZ monotherapy and in 44% (11/26) in the combination arm. Only 4 (6.6%) patients in the SSZ group and 2 (7.7%) in the ombination arm were switched to anti-TNFα therapies.
  
  
  CONCLUSIONS
  A significant subset of our AS patients responded to SSZ mono or SSZ + MTX combination therapies at 6 months follow-up. Using BASDAI, the requirement for biological therapies decreased by 21-24%. In AS patients, including those with axial involvement only, DMARD therapy may be a reasonable first alternative to anti-TNFα therapy and may delay the switch to biologic agents.
authors.affiliation: Department of Rheumatology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey. meryemkrk@gmail.com
authors.forename: Meryem
authors.initials: M
authors.lastname: Can
authors.forename: Sibel Z
authors.initials: SZ
authors.lastname: Aydın
authors.forename: Adil
authors.initials: A
authors.lastname: Niğdelioğlu
authors.forename: Pamir
authors.initials: P
authors.lastname: Atagündüz
authors.forename: Haner
authors.initials: H
authors.lastname: Direskeneli
mesh_terms: D000328:Adult; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001688:Biological Products / Q000627:therapeutic use*; D015415:Biomarkers / Q000097:blood; D001799:Blood Sedimentation; D002097:C-Reactive Protein / Q000032:analysis; D057915:Drug Substitution; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use*; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013167:Spondylitis, Ankylosing / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology; D012460:Sulfasalazine / Q000627:therapeutic use*; D013997:Time Factors; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D015415:Biomarkers; D014409:Tumor Necrosis Factor-alpha; D012460:Sulfasalazine; D002097:C-Reactive Protein; D008727:Methotrexate