EULAR 2014 | Daily Highlights

Abstract: SAT0374
Presenter: Xenofon Baraliakos
Co-Authors: U. Kiltz, F. Heldmann, H. Appel, F. Dybowski, M. Igelmann, L. Kalthoff, D. Krause, H.-J. Menne, E. Saracbasi, E. Schmitz-Bortz, J. Braun

Background:
Patients classified as axial spondyloarthritis (axSpA) may have ankylosing spondylitis (AS) or non-radiographic axSpA (nr-axSpA). Treatment recommendations for AS consider non-steroidal anti-inflammatory drugs (NSAIDs) as first-line therapy. After an unsatisfactory response to at least 2 non-steroidal anti-inflammatory drugs (NSAIDs) within 4 weeks (wk), anti-TNF agents are to be considered. However, it is unknown whether patients with nr-axSpA and AS respond similarly well to NSAIDs.

Methods:
Consecutive patients (pts) with axSpA (n=50 with nr-axSpA and n=50 with AS) were included in a prospective study if their BASDAI level was ?4, if they had not yet received the maximally approved dose of NSAIDs and if they had not been treated with anti-TNF agents to date. After inclusion the maximal dose of NSAIDs was administered over 1wk and the dose was then adapted in case of BASDAI <4 or, in case of BASDAI ?4, the NSAID was changed and the pt was treated for another 3 wk at the maximal dose. Clinical and laboratory parameters and dosage of drugs were assessed by using the ASAS NSAID-index. Magnetic resonance images (MRI) of the sacroiliac joints including STIR sequences were performed and scored by the Berlin score. Data were collected before (BL) and after 1 and 4 wk of treatment.

Results:
nr-axSpA pts were more often female than AS pts (52% vs. 70%), were younger (mean age 37.6±11 vs. 41.9±12.3 years), and had a shorter symptom duration (7.3±9.1 vs. 14.6±11.837.6±11 years) but were similarly often HLA-B27+ (74% vs. 80%), all p=n.s.. Significant differences between the groups were found in mean CRP levels (0.6±0.9 vs. 1.2±1.1) and mean MRI scores (3.1±3.0 vs. 6.7±5.4) in nr-axSpA vs. AS pts, respectively, both p<0.001. Prior to treatment, the ASDAS-CRP was >2.1 in 76% and 74% and a positive MRI occurred in 70% and 78% of pts with nr-axSpA and AS, respectively. After wk1 and wk4, both groups showed similarly increased rates in the NSAID-index and also similar responses to NSAIDs, with significant improvement from BL in all assessments with the exception of CRP levels and MRI-a scores, where almost no changes were observed. At wks 1 and 4, an ASAS20% response was found in 40% (21% with nr-axSpA and 19% with AS) and in 52% of pts (23% nr-axSpA and 29% AS), while ASAS partial remission was found in 10% (4% nr-axSpA and 6% AS) and in 16% of pts (7% nr-axSpA and 9% AS), respectively. However, 49% and 44% of all pts still had a BASDAI ?4 at wks 1 and 4, and similar results were found for an ASDAS-CRP cut-off of ?2.1, with 37% and 33% achieving this at wks 1 and 4 (no differences between nr-axSpA and AS).

Conclusions:
Patients with nr-axSpA and AS show similar response rates to NSAID treatment. Although there was some improvement of ASAS response rates, 40-50% of pts with axSpA still showed BASDAI levels >4 after 4wk of intensive NSAID therapy and were, thus, eligible for anti-TNF therapy. Bone marrow edema on MRI and CRP levels were not influenced by continuous NSAID treatment.

Disclosure of Interest:
None declared

Comment:
Die MRI-Untersuchung hat sich zur frühen Diagnose der Spondyloarthritis durch den Nachweis von entzündlichen Veränderungen im Bereich der Sakroiliakalgelenke und der Wirbelsäule etabliert. Unklar blieb jedoch inwieweit die Gabe von NSAR in den Tagen vor der Untersuchung den Nachweis von entzündlichen Veränderungen verhindern kann. Diese Studie an 100 Patienten mit konsekutiven MRI-Bildern nach 1 Woche und 4 Wochen belegt, dass NSAR eine gute klinische Wirkung nicht nur bei Patienten mit eindeutiger Spondylitis ankylosans, sondern auch bei Patienten mit nicht-röntgenologischer axialer Spondyloarthritis zeigen. Das im MRI nachweisbare Knochenmarksödem wird durch NSAR nicht beeinflusst. Ebenfalls zeigt sich im Blut keine Reduktion der CRP-Werte durch eine kontinuierliche NSAR-Gabe.

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