From the Guidelines
As a professional medical consultant, I would recommend adalimumab as the first-line biologic treatment for axial spondyloarthritis over tofacitinib, based on the most recent and highest quality study available 1.
Key Considerations
- Efficacy and Safety: Adalimumab, a TNF inhibitor, has a longer track record of efficacy and safety in axial spondyloarthritis, with significant improvements in disease activity, function, and quality of life in numerous clinical trials and real-world studies.
- Dosing: The typical dosing for adalimumab is 40 mg subcutaneously every other week.
- Alternative Options: Tofacitinib, a JAK inhibitor, is a newer option for axial spondyloarthritis, but it has less long-term safety data compared to adalimumab, with a usual dose of 5 mg orally twice daily.
- Treatment Strategy: If adalimumab is ineffective or not tolerated, switching to another TNF inhibitor (such as etanercept or infliximab) would be the next step, with tofacitinib considered as a third-line option for patients who have failed multiple TNF inhibitors.
Patient-Centered Approach
- Individualized Treatment: Treatment should be individualized based on the patient's specific clinical presentation, comorbidities, and preferences.
- Regular Monitoring: Regular monitoring for efficacy and adverse effects is crucial with either medication.
- Alternative Therapies: In cases where biologics are contraindicated or unavailable, conventional DMARDs like sulfasalazine (2-3 g daily) or methotrexate (15-25 mg weekly) may be used, although their efficacy in axial disease is limited.
Guideline Recommendations
- The Pan American League of Associations for Rheumatology recommends adalimumab as a first-line biologic treatment for axial spondyloarthritis, based on the risk-to-benefit ratio and the quality of the evidence available 1.
- The guidelines emphasize the importance of individualized treatment and regular monitoring, and provide recommendations for alternative therapies and treatment strategies.
From the Research
Comparison of Adalimumab and Tofacitinib in Axial Spondyloarthritis
- Adalimumab is a fully human, recombinant, monoclonal IgG1 antibody specific for the cytokine tumour necrosis factor-α, approved for the treatment of various inflammatory disorders, including severe non-radiographic axial spondyloarthritis (axSpA) 2, 3.
- Tofacitinib, an oral Janus kinase inhibitor, is a putative choice in the treatment of axial spondyloarthritis (AxSpA) 4.
- A real-world clinical context multicenter study compared the effectiveness and tolerability of tofacitinib with adalimumab in AxSpA, and found that tofacitinib showed comparable effectiveness with adalimumab in patients with AxSpA at the sixth month, despite lesser response in the initial months, with favorable Incremental Cost-Effectiveness Ratio (ICER) 4.
- Adalimumab has been shown to be clinically effective and reasonably safe in the short-term and long-term treatment of patients with AS who do not respond to standard therapy, and also in patients with nonradiographic axial spondyloarthritis (nr-axSpA) but only in the presence of objective signs of active inflammation 2, 5.
- A multicentre, randomised, double-blind study found that continued adalimumab therapy was associated with significantly fewer patients flaring than was treatment withdrawal in patients with active non-radiographic axial spondyloarthritis who achieved sustained remission with adalimumab 6.
Efficacy and Safety
- Adalimumab significantly decreased inflammation in the spine and sacroiliac joints, as measured by MRI, and improved spondyloarthritic and general measures of health-related quality of life at 12 weeks 2.
- Tofacitinib showed comparable effectiveness with adalimumab in patients with AxSpA at the sixth month, with a higher proportion of patients achieving BASDAI50 response and ASDAS low disease activity in the adalimumab group 4.
- Adalimumab was generally well tolerated in clinical trials of non-radiographic axSpA, with an adverse event profile similar to that in patients with AS or other approved indications 2, 6.
Treatment Outcomes
- A higher proportion of patients in the tofacitinib group than in the adalimumab group required change in therapy (14.8% vs. 7.6%, respectively) 4.
- The ICER for adalimumab compared with tofacitinib was US $188.8 per patient in the adalimumab group for each person-month with BASDAI <4 4.
- Continued adalimumab therapy was associated with significantly fewer patients flaring than was treatment withdrawal in patients with active non-radiographic axial spondyloarthritis who achieved sustained remission with adalimumab 6.