Axial spondyloarthritis is an inflammatory condition that significantly impairs quality of life. Biologic agents and other treatments may improve physical and mental health.
Axial spondyloarthritis is an inflammatory condition that has a significant impact on health-related quality of life (HRQOL) for patients. Unlike rheumatoid arthritis―which causes joint damage primarily through bone and cartilage resorption and destruction―axial spondyloarthritis is characterized by new bone formation. The condition is a progressive bony fusion of the spine that is often accompanied by pain, stiffness, fatigue, sleep problems, depression, and sexual dysfunction. “The myriad of symptoms associated with axial spondyloarthritis can have a profound impact on HRQOL and limit work, leisure, and daily activities,” says Jasvinder A. Singh, MD, MPH.
Disease progression varies, but in general, patients aged 40 and younger at disease onset most often have a predominance of axial symptoms, whereas those with later disease onset tend to have more peripheral manifestations. Women experience a greater burden of axial spondyloarthritis than men because they are more likely to develop severe symptoms in shorter timeframes and they are less likely to respond to standard treatments.
Dr. Singh says that a delayed diagnosis of axial spondyloarthritis can have a significant impact on patients. “Many patients go decades without getting accurately diagnosed because the disease mimics other common medical conditions,” he adds. “Clinicians should suspect axial spondyloarthritis as a possible diagnosis if patients present with telltale signs and symptoms of the disease, including joint and back pain and functional disability, but also other conditions like bowel disease, psoriasis, eye disease, dactylitis, and enthesitis.”
Assessing Treatment Options
Current guidelines indicate that the primary goals of treating patients with axial spondyloarthritis are to maximize long-term HRQOL outcomes with the control of symptoms and inflammation, prevent progressive structural damage, and preserve and/or normalize function and social participation. Common non-pharmaceutical treatments for patients with axial spondyloarthritis include exercising regularly to improve functioning, participating in physical therapy, and making adjustments to daily routines to improve life and work environments (Table). Advocacy organizations, self-help groups, and other educational resources can further inform patients on behavioral and lifestyle modifications.
“When managing diagnosed patients, clinicians should recognize that traditional disease-modifying antirheumatic drugs and NSAIDs are often ineffective for improving HRQOL in patients with axial spondyloarthritis,” Dr. Singh says. As such, biologic agents like tumor necrosis factor α (TNF-α) inhibitors should be considered. Research shows that use of TNF-α therapy has correlated with a global improvement of HRQOL for some patients. Clinicians can also switch from one biosimilar therapy to another if patients experience treatment failure.
More Help Coming
New therapies with novel mechanisms of action for axial spondyloarthritis are needed to stop or slow disease progression, and some have the potential to reverse damage caused by the disease. Dr. Singh says targeting novel pathways may uncover new disease manifestations and improve clinicians’ understanding of how the condition affects patients. Newer biologic agents, such as those targeting the interleukin 17–interleukin 23 axis, have had promising efficacy in clinical studies involving patients with axial spondyloarthritis.
Clinical research is needed to evaluate current and emerging therapies based on outcomes that are important to patients, including HRQOL. In addition, cost-utility analyses are warranted to determine the economic benefit of these agents. “Groups like the American College of Rheumatology have developed guidelines for spondyloarthritis, but more guidance is needed on optimizing the diagnosis and treatment of the different forms of the disease,” says Dr. Singh.
Taking a Holistic Approach
Clinicians should be vigilant about taking a proactive and holistic approach to axial spondyloarthritis, according to Dr. Singh. “Efforts are needed to reduce diagnostic delays because they are likely to significantly impact HRQOL,” he says. “Ideally, when symptoms occur, clinicians should collaborate with other specialists to ensure that patient care is individualized and tailored. Lifestyle modifications and other interventions should be recommended in an effort to improve patients’ HRQOL.”
Strand V, Singh JA. Patient burden of axial spondyloarthritis. J Clin Rheumatol. 2017;23:383-391. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617559/pdf/rhu-23-383.pdf.
Reveille JD, Witter JP, Weisman MH. Prevalence of axial spondylarthritis in the United States: estimates from a cross-sectional survey. Arthritis Care Res (Hoboken). 2012;64:905-910.
Strand V, Rao SA, Shillington AC, et al. Prevalence of axial spondyloarthritis in United States rheumatology practices: assessment of SpondyloArthritis International Society criteria versus rheumatology expert clinical diagnosis. Arthritis Care Res (Hoboken). 2013;65:1299-1306