AxSpa Treatments: TNF Inhibitors, NSAIDs, and Opioids

Hillary Norton, MD: Some of the non-pharmacologic treatments that are important are exercise. Exercise is really the cornerstone of therapy for all axSpA [axial spondyloarthritis] patients, whether it is formal physical therapy, water exercise, or an individualized exercise program. A healthy diet, which looks different for every patient, is also important. Not smoking is important. There is a strong correlation between smoking and worsening of disease, and we know that the treatments don’t work as well in patients who smoke.

The nonpharmacologic approaches should be considered for all patients, even patients who are on pharmacologic treatment as well.

The treatment for AS [ankylosing spondylitis] starts with nonsteroidal anti-inflammatories [NSAIDs]. If these are no longer sufficient, then we treat with tumor necrosis factor [TNF] inhibitors. And IL-17 inhibitors are also approved in the US [United States] for the treatment of AS.

We try to avoid the use of opioids in treatment of axSpA in AS. These don’t address the underlying cause of the disease, and when we do treat the disease appropriately with approved medications, this treats pain as well as the underlying cause of the disease. There are many known risk factors with the use of long-term opioids, so we try to avoid this.

Treatment of AS starts with NSAIDs. They work very well in early disease. So most patients have taken multiple NSAIDs by the time they get in to see a rheumatologist, and a scheduled trial of these is rarely warranted. We move to biologics for AS if the disease is still active despite NSAID therapy. TNF inhibitors and IL-17 inhibitors are both approved in the AS, in the US for treatment of AS.

TNF inhibitors are a group of biologic medications that work by modulating the immune response. Tumor necrosis factor is an inflammatory cytokine that is implicated in the pathogenesis of AS. These medications are very effective in treating AS. In general, I would use these in a young, otherwise healthy patient who doesn’t have signs of acute or chronic infection.

TNF inhibitors are approved in Europe for treatment of non-radiographic axSpA as AS, and we anticipate that approval will happen in the US eventually as well.