Clinical expertise using various nonpharmacologic and pharmacologic therapies, including newer biologic agents, in the treatment of axial spondyloarthritis, and suggestions for ensuring treatment coverage to patients.
Atul A. Deodhar, MD: The use of opioids is quite common in this population, mainly because back pain is so common in this population. Depending on which survey you look at, 30% to 40% of the patients would admit to taking some kind of opioids. We have excellent new medication, and we should be able to control their pain without the use of opioids. And if medication is appropriately used, the patients need not use opioids at all.
The other problem now, of course, is that opioids don’t really take care of the inflammation, and this is an inflammatory disease, and you really have to treat the underlying inflammation because that is what the root of new bone formation is—and later on, disability. Taking just pain medication is like masking the pain. It doesn’t really work on the underlying disease itself. So I tell my patients that if you have pain, let me know. I can do something about it. Inflammation needs to be treated much more aggressively in these patients.
As I said earlier, there is nonpharmacologic treatment and pharmacologic treatment for axial spondyloarthritis. We always start with nonpharmacologic treatment, which is mostly physical therapy, which really helps in improving the quality of life and even improving the pain. That’s why activity improves their back pain. The second one, of course, is a nonsteroidal anti-inflammatory drug, but that is pharmacologic treatment. The first level of pharmacologic treatment is nonsteroidal anti-inflammatory drugs, and they help immensely in reducing the inflammation and pain in these patients.
If patients have tried a couple of nonsteroidal anti-inflammatory drugs for the full dose for up to a month and they still have significant back pain, then we suggest starting biological therapy. And the first class we usually use is the anti-TNF drugs, or tumor necrosis factor inhibitors. And if that doesn’t work, the next class would be interleukin [IL] 17 inhibitors. And both of these classes of drugs, in fact, originated after we studied the basic pathophysiology of this disease. And what we found was in the areas where the inflammation is affecting the patient, namely the sacroiliac joint, namely the spine, and also the peripheral joints, the tumor necrosis factor inhibitor is expressed. It’s kind of released by the immune system cells. So blocking the TNF is very scientific because that is 1 of the reasons why these patients are getting the inflammation, the pain, the swelling, the stiffness, and the fatigue.
More recently, it has been found that IL-23, IL-17 axis is very important in the pathology of ankylosing spondylitis. And this again was found to be high. IL-17 is high in the serum of patients with axial spondyloarthritis. It has been found in the tissue samples of these patients in their spine and in the sacroiliac joints, etc. And so IL-17 inhibitors have been used in the treatment of axial spondyloarthritis and have been found to be very effective.
With anti-TNF drugs, we have got longer experience. So we will use them first, and if a patient fails the anti-TNF drug after trying it for some time, then that’s a secondary failure, in which case we could try a second anti-TNF drug. And interestingly, patients may respond to a second drug. If there is a primary failure to the anti-TNF, then we will move straight to the IL-17 inhibitor, and there are 2 of those currently available for the treatment of axial spondyloarthritis.
In my experience, both of these agents have completely changed the face of axial spondyloarthritis. Previously, we were stuck just using nonsteroidal anti-inflammatory drugs and physical therapy, and our drugs that we otherwise use in rheumatology, the conventional synthetic DMARDs—or disease-modifying anti-rheumatoid drugs—like methotrexate and sulfasalazine, those have no role to play in ankylosing spondylitis and axial spondyloarthritis. So we did not have very many options available until recently with the advent of anti-TNF drugs, and now with IL-17 drugs, and there is another class of drugs, which is currently being investigated, which are the JAK [Janus kinase] inhibitors. These are oral pills, and these are intracellular signaling inhibitor molecules.
We are now entering into an era where we will have more and more potent options to control the signs and symptoms and hopefully also prevent further radiographic damage in the patients with axial spondyloarthritis. My own experience tells me that now, with the current armamentarium that we have, we can definitely give much better quality of life to these patients and prevent disability if we catch them early and if we treat them aggressively.
Currently, ankylosing spondylitis has an ICD-9 [International Classification of Diseases, Ninth Revision] and ICD-10 code. Axial spondyloarthritis, as I said earlier, is a new concept, and nonradiographic axial spondyloarthritis does not have an ICD-9 or ICD-10 code. And this definitely impacts our ability to research this area as to how commonly this diagnosis is being made by rheumatologists, etc. People—my colleagues, providers, physicians, rheumatologists—are using ankylosing spondylitis as the code for nonradiographic axial spondyloarthritis, or they use a general code for spondyloarthritis when they are describing nonradiographic axial spondyloarthritis.
I’m aware that ICD-11, which is already available, has a code for nonradiographic axial spondyloarthritis and axial spondyloarthritis in general, as well as for ankylosing spondylitis or radiographic axial spondyloarthritis. So when we start using ICD-11, that is going to be beneficial because we will definitely know then the prevalence of this condition, how commonly people are seeing these patients, and how they are treating in day-to-day life.