title: Should axial spondyloarthritis without radiographic changes be treated with anti-TNF agents?
abstract: A spectrum of disease extends beyond the rigid confines of ankylosing spondylitis (AS). Axial spondyloarthritis (axSpA) encompasses non-radiographic axSpA (nr-axSpA) in individuals without established radiographic changes but with other clinical/imaging axSpA features and AS in those with definite sacroiliac joint changes on pelvic X-rays. A broad consensus about the management of nr-axSpA is emerging among clinicians, but the evidence base remains open to question. To explore whether nr-axSpA and AS should be treated similarly, we examined the literature on their prevalence, natural history, disease burden, and treatment. There is strong evidence that nr-axSpA and AS are expressions of the same disease. Approximately 10% of patients with nr-axSpA will develop radiographic disease over 2 years; after >20 years, the figure may exceed 80%. Nr-axSpA patients have lower CRP and less spinal inflammation on MRI than AS patients but similar disease activity, pain, and quality-of-life impairment. Most patients with nr-axSpA manage well with conservative treatment, but a minority has severe disabling symptoms. Anti-TNF therapy has demonstrated similar efficacy and safety in nr-axSpA and AS. Current evidence does not clearly indicate that anti-TNF treatment can inhibit or limit bony progression of AS, the basis of conservative and anti-TNF treatment is control of symptoms and function. For some patients with nr-axSpA, the need for powerful treatments is as great as in some with AS; thus, treatment of axSpA should be consistent across the axSpA spectrum with anti-TNF agents being available, irrespective of radiographic change, according to the same criteria as those applied to AS.
authors.affiliation: Rheumatology Department, Arthritis Centre, Northwick Park Hospital, Harrow, Middlesex, HA1 3UJ, UK. a.keat@nhs.net.
authors.forename: Andrew
authors.initials: A
authors.lastname: Keat
authors.affiliation: NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK.|Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Headley Court, Epsom, Surrey, UK.
authors.forename: Alexander N
authors.initials: AN
authors.lastname: Bennett
authors.affiliation: Rheumatology Department, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK.
authors.forename: Karl
authors.initials: K
authors.lastname: Gaffney
authors.affiliation: NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK.
authors.forename: Helena
authors.initials: H
authors.lastname: Marzo-Ortega
authors.affiliation: Royal National Hospital for Rheumatic Diseases, Bath, UK.
authors.forename: Raj
authors.initials: R
authors.lastname: Sengupta
authors.affiliation: Pfizer Ltd, Tadworth, Surrey, UK.
authors.forename: Tamara
authors.initials: T
authors.lastname: Everiss
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001688:Biological Products / Q000627:therapeutic use*; D017281:Cost of Illness; D018450:Disease Progression; D006801:Humans; D015995:Prevalence; D011859:Radiography; D016032:Randomized Controlled Trials as Topic; D012720:Severity of Illness Index; D025242:Spondylarthropathies / Q000000981:diagnostic imaging* / Q000188:drug therapy* / Q000453:epidemiology; D013997:Time Factors; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D014409:Tumor Necrosis Factor-alpha
keywords: Ankylosing spondylitis; Axial spondyloarthritis; Burden of illness; Epidemiology; Non-steroidal anti-inflammatory drugs; Tumour necrosis factor