TNF inhibitors ‘not always’ standard of care in spondyloarthritis
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SCOTTSDALE, Ariz. — Although TNF inhibitors can work “across the spectrum” in spondyloarthritis, they are “not always” the standard of care, according to a presenter at the Basic and Clinical Immunology for the Busy Clinician symposium.
“Back to the original question of whether TNF is the standard of care, my answer is going to be, ‘not always’,” Lianne S. Gensler, MD, director of the SpA clinic and research program at the University of California, San Francisco, told attendees at the hybrid meeting. “First-line therapy for patients with active disease is NSAIDs. We need to remember that.”
Gensler discussed the case of a 21-year-old woman with intermittent and nocturnal back pain, along with significant gastrointestinal symptoms. The patient demonstrated no dactylitis and her laboratory results were borderline for SpA. However, she experienced inflammation of her sacroiliac joints and both her Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) were “quite high” for a woman of that age, Gensler said.
In addition to NSAIDs, Gensler stated that physical therapy is also critical from the early stages of treatment.
“Let’s not forget about non-pharmacotherapeutic approaches,” she said.
For the patient’s gastrointestinal complications, Gensler called for a fecal calprotectin, the results of which were normal. However, the meloxicam caused significant gastrointestinal complications, including diarrhea, constipation, stomach pain and, ultimately, ulcerative colitis.
At this juncture, Gensler called for a colonoscopy with a GI colleague, which highlights another important consideration for spondyloarthritis management for a rheumatologist. “Multidisciplinary care is the way we operate,” she said.
The patient was switched to celecoxib, but there was a worsening of symptoms. Meanwhile, she presented with severe pustular psoriasis and inflammatory bowel disease.
“This is where a TNF inhibitor becomes the standard of care,” Gensler said, noting that a monoclonal antibody is often most effective in the setting of axial SpA and IBD, along with the pustular psoriasis. “This is a good example of where a TNF inhibitor really works across the spectrum.”
That said, Gensler acknowledged that there are several other drug classes that can be used in patients with SpA, particularly when a TNF inhibitor is not tolerated or contraindicated.
These include Janus kinase inhibitors, which can work across axial SpA, psoriatic arthritis, psoriasis, Crohn’s disease and ulcerative colitis, Gensler said.
Etanercept (Enbrel, Amgen) and interleukin-17 inhibitors can also be used in axial SpA and cutaneous manifestations, but are less effective the GI sphere. IL-23 inhibitors and tyrosine kinase (TYK)-2 inhibitors may also be used in certain populations.
Although every patient with SpA is unique and should be managed individually, Gensler offered some take-home points based on her experience with this case.
“NSAIDs are still the standard of care for first-line therapy unless they have IBD, then TNF inhibitors will become standard of care,” she said. “In the presence of TNF inhibitor adverse events or contraindications, certainly other mechanisms of action are preferred.”
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Gensler L. SpA - is TNF still the standard of care? Presented at Basic and Clinical Immunology for the Busy Clinician, Feb. 25-26, 2023; Scottsdale, Arizona (hybrid meeting).
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