BSR guidelines for prescribing TNF-α blockers in adults with ankylosing spondylitis. Report of a working party of the British Society for Rheumatology

Abstract

Two TNF-blocking drugs are now licensed for the treatment of ankylosing spondylitis (AS) and there is clear evidence of symptomatic efficacy. It is recognized that the instruments for analysing aspects of AS and the outcomes of treatment are imperfect, though they are validated and adequate for the purpose. This document provides guidance to enable consultant rheumatologists in the UK to balance the demonstrated merits of TNF blockade treatment against the known and unknown potential toxicity. Background AS is an inflammatory condition primarily affecting the spine. Onset is most common in the third decade of life, though the disease may remain symptomatic and progressive throughout life. It is part of the family of spondyloarthropathies, which also includes psoriatic arthritis, reactive arthritis and enteropathic arthritis. Undifferentiated forms of spondyloarthopathy, often presenting as mono- or oligoarthritis, are also recognized, as are juvenile forms of spondyloarthopathy, in which the spine is not affected but may become so later. Thus, many individuals with AS also suffer from involvement of the hips, peripheral joints and peripheral entheses as well as periodic eye inflammation, inflammatory bowel disease and psoriasis. The treatment of axial and peripheral elements of this disease therefore requires distinct criteria and guidance that is specific for the particular feature. Symptoms may persist throughout adult life, though some patients experience a diminution of symptoms or even remission of active disease after a period of years. The consequences of active spinal disease, including spinal stiffness or rigidity and increased risk of spinal fracture, are irreversible.