Treatment Strategies for nr-axSpA

Transcript: Sergio Schwartzman, MD: Philip, I’m going to put you on the spot in 2 ways. No. 1, I’m going to ask you about some specific therapies or therapeutic classes. No. 2, I’m going to ask you to be concise in your approach to them, which should be easy with some of these. The first is the nonsteroidal anti-inflammatory agents that Atul already mentioned. Just give us a sense as to how you choose from them and for how long a period of time. Next is going to be the DMARDs [disease-modifying anti-rheumatic drugs]. Is there any role for medications like sulfasalazine, leflunomide, methotrexate, steroids, and opioids? What’s your perspective on these therapies?

Philip J. Mease, MD: A cornerstone of treatment can be of the nonsteroidals, and the recommendations all suggest that we should be trying, that I should at least give a good clinical trial of at least 2 different nonsteroidals. This is if the first 1 should fail, to try a second 1. Many patients, of course, have tried these already, because ibuprofen and naproxen are available over the counter in the forms of ibuprofen and Aleve [naproxen]. Many patients will have tried these already.

There are a few patients—not many, but a few—who I feel get adequate treatment with nonsteroidals alone. They may use them either on an ongoing or steady basis or on what we call prn, or as needed. There is conflicting evidence about whether there’s value in having steady ongoing use vs prn. Of course, the patient needs to take into account potential adverse effects, such as gastric irritability or even ulceration of the stomach.

There needs to be periodic monitoring of kidney and liver tests, particularly the kidney test creatinine, to be sure that the nonsteroidal use is not leading to renal or kidney insufficiency. This is very straightforward and should be followed by patients. As rheumatologists, we’re typically seeing them at a time when we need to add other layers of treatment beyond the nonsteroidals. In terms of the disease-modifying drugs—the older ones—there is no evidence that they could be helpful in treating spine symptoms.

Methotrexate, sulfasalazine, and leflunomide we don’t use for the purpose of spine symptoms. There is some evidence, mainly be with sulfasalazine, that peripheral manifestations of the disease, such as a pesky monoarticular knee arthritis, might be helped by of 1 of these medications. That would be legitimate to use in that context. Another issue that sometimes comes up is with some of the biologics that may lead to the development of antidrug antibodies against that biologic, such as 1 or 2 of the TNF [tumor necrosis factor] inhibitors.

We will sometimes use low-dose methotrexate to try to eliminate or reduce the chance that those antibodies may neutralize the efficacy of the biologic. But that’s different from trying to treat the symptoms and signs itself. In terms of steroids, that’s controversial in general. We don’t use chronic prednisone for treatment of the spondyloarthropathy conditions. I prefer not to do that because of the potential adverse effects of steroids. There will be occasions where, in a flare, you may want to use a tapering course of prednisone.

Of course, there might be occasions where you use an intra-articular steroid; for example, that pesky knee that I mentioned. Some will even inject in the context of a difficult enthesitis, although I usually avoid injecting around the Achilles tendon, lest we create a situation for rupture. Lastly, in relation to opioids, that’s an important and difficult subject. We in our clinic assiduously avoid use of opioids, particularly chronic opioid use, because of the issues of dependency.

Sometimes there is a reasonable biology that taking too much in the way of opioids can actually facilitate or increase our pain augment in an individual. We really try the best we can to avoid use of them. Oftentimes, patients will come in hooked on opioid therapy, and we have to work to get them off opioids. To do that, we need to use other nonopioid medications that can be useful for treating their condition, including the biologics, our targeted synthetic DMARDs, and other medicines, including nonsteroidals or nonnarcotic analgesics, that may be useful for treatment.

Sergio Schwartzman, MD: Thank you.

Transcript Edited for Clarity