Recommendations for Prescribing TNF Therapy in Ankylosing Spondylitis
Posted on: 10/23/06
A number of groups around the world have created their own criteria for prescribing the TNF-a inhibitors to people with ankylosing spondylitis. In the United States, there are 3 medications in this class that are FDA approved for AS that are currently available: Remicade, Enbrel and Humira.
The most recent of groups to publish their recommendations is the French Society of Rheumatology. Interestingly enough, they are very similar to the recently updated ASAS (Assessment of Ankylosing Spondylitis) group's criteria - and international AS research and assessment group.
Click here to read the French Society of Rheumatology's recommendations.
Click here to read the ASAS group's recommendations.
Similar recommendations are sometimes used in the USA and were based on the original ASAS criteria. Click here to view both in a side-by-side comparison.
So, why so many criteria before using a TNF-a inhibitor? John D. Reveille, MD explains, "Bottom line: TNF-a blockers are very expensive, they work, but not every one with AS needs them."
Dr. Paul Peloso adds, "We know that exercise, physical therapy and NSAIDs work fine for some people. We don't know exactly what the percentage is, but it might be as high as 50%. In addition, the TNF-blockers are very expensive, and they have potential side effects. So the real issue is, if you don't need them, why take them?"
However, the question remains, given the continued research findings that the TNF-a inhibitors appear to be safe long term (as we have previously reported), and that severe adverse reactions are appear to be rare, why aren't these medications becoming a first line therapy, especially in cases of late diagnosis and severe disease? Anecdotally, we here at SAA have heard from people with AS whose doctors did prescribe a TNF-a inhibitor as a first-line treatment, without following the aforementioned recommendations.
The authors of the latest ASAS criteria write, "It is important to realize that these are recommendations not guidelines; the lengthy discussions of the expert group for each of the 10 final points indicate that the final proposals were a synthesis of quite marked variations in opinion." And they add that, "This is considered an important starting point to provide guidance for monitoring and treatment of patients with AS.... Regular updating will be carried out to keep abreast of new developments in the management of AS."
As always, it is best to consult with your physician regarding possible treatment options.
References:
First update of the international ASAS consensus statement for the use of anti-TNF agents in patients with ankylosing spondylitis. Annals of the Rheumatic Diseases 2006;65:316-320
TNFa antagonist therapy in ankylosing spondylitis and psoriatic arthritis: recommendations of the French Society for Rheumatology. Joint Bone Spine Volume 73, Issue 5 , October 2006, Pages 547-553