Ankylosing Spondylitis at the ACR 2012 in Washington

Quite a lot of studies were addressing ankylosing spondylitis. Sorry, no "new" drugs. More bad news for smokers as you will see below. I will go into detail soon.

Link to the EULAR 2012 blog post: http://rheumatologe.blogspot.de/2012/07/ankylosing-spondylitis-refractory-to.html
Link to the ACR 2012 blog post on alterations in bone metabolism of HLA B27 positive healthy individuals:
http://rheumatologe.blogspot.de/2012/11/alterations-in-bone-metabolism-and-hla.html
Link to the ACR 2012 blog post on secukinumab in ankylosing spondylitis:
http://rheumatologe.blogspot.de/2012/12/secukinumab-at-acr-2012-in-washington.html

Smoking
     Ann B. I. Bremander and colleagues presented a study on smoking (Abstract No. 95): “Smoking Is Associated with Worse and More Widespread Pain, Worse Disease Activity, Function, Fatigue and Health Related Quality of Life in Patients with Axial Spondyloarthritis – Results From a Population Based Cohort”. Conclusion: “ …, smoking cessation should be recommended not only due to general health perspectives but also due to disease specific issues.”
     Denis Poddubnyy and colleagues presented another study on smoking (Abstract No. 1703): “Relationship Between Tobacco Smoking and Radiographic Spinal Progression in Axial Spondyloarthritis: The Role of Inflammatory Activity.” Conclusion: “Tobacco smoking has a clear dose-dependent effect on radiographic spinal progression in axial SpA, which is likely to be related to a non-specific augmentation of inflammation by the components of the tobacco smoke.”
     The two studies show that we have a clear task: getting as much of our patients off smoking.

Some studies on TNF-alpha-inhibitors
     W. Bensen and colleagues presented a study on infliximab (Abstract No. 493): “Effect of Infliximab On Employment Status in Patients with Rheumatoid Arthritis or Ankylosing Spondylitis”. The problem with such a study is comparability, but with this in mind, the authors came to a conclusion: “…, treatment with IFX was equally effective in reducing disease severity and symptoms regardless of employment status and most importantly enabled a portion of patients to return to employment.”
     Joachim Sieper and colleagues presented a study on certolizumab [CZP ] (Abstract No. 558): “Rapid Improvements in Patient Reported Outcomes with Certolizumab Pegol in Patients with Axial Spondyloarthritis, Including Ankylosing Spondyltitis and Non-Radiographic Axial Spondyloarthritis: 24 Week Results of a Phase 3 Double Blind Randomized Placebo-Controlled Study”. The authors tested 200 mg CZP every 2 weeks (Q2W) and 400 mg CZP every 4 weeks (Q4W). Conclusion: “Both dosing regimens of CZP rapidly improved all PRO [patients reported outcomes] including pain, fatigue, physical function and QoL [quality of life] of axSpA [axial spondyloarthritis] pts. CZP effectively improved patient-relevant outcomes in the broad population of axSpA pts classified using the ASAS criteria.”
     Chamaida Plasencia and colleagues looked at the immunogenicity to the first TNF inhibitor as a determinator of the outcome to a second TNF inhibitor (Abstract No. 546). Conclusion: “In SpA [spondyloarthropathy], the failure to respond to the first anti-TNF treatment due to the development of ADAs [anti-drug antibodies] predicts a better clinical response to a second anti-TNF treatment. The study of immunogenicity in biological treatment failure may help predict the response to a second biological treatment for SpA.”
     Désirée van der Heijde and colleagues presented a MRI study (Abstract No 705): “Effect of Certolizumab Pegol On Inflammation of Spine and Sacroiliac Joints in Patients with Axial Spondyloarthritis: 12 Week Magnetic Resonance Imaging results of a Phase 3 Double Blind Randomized Placebo-Controlled Study”. Conclusion: “CZP reduced inflammation in the SI [sacroiliac] joints and spine, as assessed by MRI in pts with axSpA [axial spondyloarthritis], and in both AS [ankylosing spondylitis ] and nr-axSpa [non-radiographic axial spondyloarthritis] populations.”
     Susan Bolge and colleagues looked at patient satisfaction (Abstract 1925): “Patient Satisfaction and Experience with Golimumab, Adalimumab, and Etanercept for the Treatment of Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis”. Conclusion: “Patient reported satisfaction with effectiveness is comparable among patients treated with GLM, ADA and ETN, and less discomfort, pain, burning, and stinging with injection is reported by GLM patients. Patient injection experience may be an important consideration in selection of biologic treatment. Future research should explore potential effects of patient injection experience on treatment adherence and patient outcomes.”
     Ioan Ancuta and colleagues presented a study on cost effectiveness of TNF inhibitors in the treatment of ankylosing spondylitis in Romania (Abstract No. 1383). Conclusion: “For the vast majority of endpoints, including BASDAI index, there were no statistically significant differences in treatment efficacy between the investigated groups at any assessment. Therefore, we suggest that treatment cost, rather than active compound, might be taken into consideration when choosing between these three anti-TNF alpha drugs for treatment of autoimmune AS”.
     Robert B. M. Landewé and colleagues presented another study on certolizumab (Abstract No. 777): “Effect of Certolizumab Pegol On Signs and Symptoms of Ankylosing Spondyltitis and Non-Radiographic Axial Spondyloarthritis: 24 Week Results of a Double Blind Randomized Placebo-Controlled Phase 3 Axial Spondyloarthritis Study”. Conclusion: “CZP effectively and rapidly reduced the signs and symptoms of axSpA, including spinal mobility, with no new safety signals observed. Improvements were similar across CZP dosing regimens, and observed in both AS and nr-axSpA pts.”
     What do we get out of these studies? TNF inhibitors like Infliximab help patients to get back to work. There are differences in cost effectiveness, as shown in Romania. Certolizumab is going to join the competition in treating ankylosing spondylitis. The development of anti-drug antibodies in the first TNF inhibitor predicts a better clinical response to a second TNF inhibitor.

More studies on different topics
     Victoria Navarro-Compa’n and colleagues looked at biomarkers and response in patients under TNF inhibitors ( Abstract No. 538): Association Between Biomarkers (Metalloproteinase-3, Dikkopf-1 and Sclerostin) with Disease Activity and Prediction of Anti-TNF-alpha Therapy Response in Patients with Ankylosing Spondylitis”. Conclusion: “No correlation was observed between serum levels of MMP-3, DKK-1 and sclerostin and disease activity parameters in patients with AS. Serum levels of MMP-3 may be useful to predict response to anti-TNF-alpha therapy in patients with AS”. Too bad, we would have liked to have a predictive biomarker.

     Daniel Wendling and colleagues looked at: “Anterior Chest Wall Pain in Recent Inflammatory Back Pain. Data From the DESIR Cohort” (Abstract No. 544). The DESIR cohort is a prospective, multicenter French cohort of patients with early inflammatory back pain (Calin or Berlin criteria applied), duration 3 months to 3 years, suggestive of ankylosing spondylitis to the investigator (I would have voted for less soft criteria). Conclusion: “In recent IBP suggestive of SpA, presence of ACW is associated with enthesitis, thoracic spine involvement, radiographic sacroiliitis and the diagnosis of ankylosing spondylitis. …”. I’ll sure be looking, that anterior chest wall pain is part of history taking in new patients at our centers. I remember a recent patient, who complained about anterior chest wall pain, but up to now we haven’t been asking for anterior chest wall pain routinely.
     Annalina Braun and colleagues presented a study on HLA B27 (Abstract No. 553): “Identification of Axial Spondyloarthritis Among Patients with Chronic Back Pain in Primary Care – How Does Determination of HLA B27 Influence the Performance of Clinical Assessments of Inflammatory Back Pain?” Conclusion: “This study shows that patients with axSpA [axial spondyloarthritis] can be identified with or without knowledge of HLA B27 based on questions specific for IBP in primary care. However, since models including HLA B27 had better predictive results in this study, it seems to be more useful to generally determine HLA B27 in all patients with chronic back pain of young age in primary care to further reduce the delay in diagnosing axSpA.” I guess most of us are doing this already, but it’s good to know doing it according to research results.
     Gareth T. Jones and colleagues looked at BASFI and BASDAI as indicators of poor quality of Life (Abstract No. 601): “Bath Ankylosing Spondylitis Functional Index (BASFI) Is a Better Indicator of Poor Quality of Life Than Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in Ankylosing Spondylitis: Results From SIRAS – the Scotland and Ireland Registry for Ankylosing Spondylitis”. Conclusion: “As it is integral to anti-TNF prescribing guidelines, disease activity (BASDAI) is considered as the important clinical indicator in AS. However, clinicians should be aware that function (BASFI) is a stronger predictor of poor QoL. Patients with a high BASFI were almost five times more likely to report poor QoL than other patients. In addition, after adjusting for BASFI, few other clinical variables were independently associated with QoL“.

I still have more studies, which I wanted to present, but then I might end up quoting all the abstracts concerning ankylosing spondylitis. So I stop here. The 2012 ACR meeting in Washington has been extremely interesting in studies concerning ankylosing spondylitis.