Switching of Tumour Necrosis Factor-alpha Antagonists in Patients with Spondyloarthritides

Antonio Spadaro
European Musculoskeletal Review, 2011;6(1):30-33
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Abstract

Abstract
Tumour necrosis factor-alpha (TNFα) antagonists (adalimumab, etanercept and infliximab) have demonstrated effectiveness in controlling disease acitivity in spondyloarthritides, such as psoriatic arthritis and ankylosing spondylitis. Nevertheless, in controlled and observational studies with TNFα blockers, a variable percentage of patients, withdraw from therapy because of failure (primary or secondary lack of efficacy) or poor tolerability. In the case of treatment failure with one agent, switching to the other agent may also be rational due to the different chemical structures and mechanisms of action of available TNFα blockers. Moreover, the rationale for switching is supported by the evidenceof beneficial effects reported in patients resistant or intolerant to TNFα antagonists. This suggests that treatment with another anti-TNFα agent monoclonal antibody or recombinant soluble TNF receptor) may be appropriate and leads to a prompt and sustained response, with the majority of patients tolerating these drugs well.

Keywords
Switching, spondyloarthritides, psoriatic arthritis, ankylosing spondylitis, tumour necrosis factor-alpha

Disclosure: The author has no conflicts of interest to declare.
Received: 14 February 2010 Accepted: 1 November 2010 Citation: European Musculoskeletal Review, 2011;6(1):30–2
Correspondence: Antonio Spadaro, Dipartimento di Clinica e Terapia Medica, Divisione di Reumatologia, Sapienza, Università di Roma, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy. E: a.spadaro.reuma@virgilio.it

The spondyloarthritides (SpA) include1 ankylosing spondylitis (AS), psoriatic arthritis (PsA), reactive arthritis, arthritis associated with inflammatory bowel diseases and forms that fail to meet established criteria for definite categories, which are designated as undifferentiated spondyloarthropathies. The most common sites ofskeletal inflammation in SpA include the sacroiliac joints, entheses, vertebral bodies adjacent to intervertebral discs and peripheral joint synovium. Many of these lesions are poorly accessible. An important role for tumour necrosis factor-alpha (TNFα) has, however, been demonstrated in the pathogenesis of SpA.

Spondyloarthritides and Tumour Necrosis Factor-alpha
Despite the fact that data on serum levels of TNFα in AS are conflicting, in early sacroiliitis there is synovitis characterised by myxoid-appearing bone marrow and the subsequent formation of pannus and granulation tissue, with overexpression of TNFα.2 In PsA, TNFα levels are significantly higher in the synovial fluid than in osteoarthritis, although they are lower than in rheumatoid arthritis (RA).3 Elevated TNFα levels were also found in supernatants from explant cultures of psoriatic synovium.4 Moreover, cells containing TNFα and TNFβ were consistently found in the synovial lining layer, in the infiltrates and in the blood vessels.5

Treating Spondyloarthritides with Tumour Necrosis Factor-alpha Antagonists
hese studies represent the rationale to treat PsA and AS with TNFα antagonists, such as adalimumab, etanercept and infliximab. Anti- TNFα drugs have demonstrated effectiveness in SpA when using such common outcome measures as the Psoriatic Arthritis Response Criteria,6 the ASsessment in Ankylosing Spondylitis (ASAS) response7 and the Bath AS Disease Activity Index.8 The clinical response rate varied from 62 to 87% when using Psoriatic Arthritis Response Criteria in patients with PsA.9 The response using the Bath AS Disease Activity Index-50 in AS patients also varied, from 43 to 71%.9 Despite this, in controlled and observational studies with TNFα antagonists, a variable percentage of patients withdraw from therapy because of failure (primary or secondary lack of efficacy) or poor tolerability.10–17

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