What is the treatment approach for patients with difficult to treat Spondyloarthropathy?

Treatment Approach for Difficult to Treat Spondyloarthropathy

For patients with difficult to treat spondyloarthropathy, treatment with IL-17 inhibitors (secukinumab or ixekizumab) is recommended after failure of TNF inhibitors, particularly in cases of primary non-response to TNF inhibitors. 1

First-Line Treatment Options

• NSAIDs remain the cornerstone of initial therapy for active spondyloarthropathy, with strong recommendations for their use over no treatment 1
• Continuous NSAID treatment may be preferred during active disease periods, though on-demand treatment is recommended for stable disease 1
• No particular NSAID is recommended as the preferred choice; selection should be based on patient-specific factors 1
• Physical therapy is strongly recommended as part of the treatment plan for all patients with spondyloarthropathy 1

Treatment Progression for Difficult Cases

After NSAID Failure:

• TNF inhibitors (TNFi) are strongly recommended as the next step when NSAIDs fail to control disease activity 1
• No particular TNFi is recommended as the preferred choice except in specific circumstances:
  • For patients with concomitant inflammatory bowel disease or recurrent iritis, TNFi monoclonal antibodies are strongly recommended over etanercept 1

After TNFi Failure (Difficult to Treat Cases):

1. For primary non-response to first TNFi:

   • IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended over switching to a different TNFi 1
   • Secukinumab has demonstrated significant improvements in ASAS40 responses in clinical trials 2

2. For secondary non-response to first TNFi:

   • Switching to a different TNFi is conditionally recommended over non-TNFi biologics 1

3. Additional recommendations for difficult cases:

   • Against adding sulfasalazine or methotrexate to TNFi therapy; instead, transition to a new biologic 1
   • Against switching to a biosimilar of the first TNFi when the original TNFi fails 1
   • Against discontinuation of biologics in patients who are responding 1
   • Against tapering biologic dose as a standard approach 1

Important Considerations

• Systemic glucocorticoids are strongly recommended against in the treatment of spondyloarthropathy 1

• Local glucocorticoid injections may be considered for:

  • Isolated active sacroiliitis 1
  • Stable axial disease with active enthesitis (avoiding injections of Achilles, patellar, and quadriceps tendons) 1
  • Stable axial disease with active peripheral arthritis 1

• Regular monitoring of disease activity using validated measures and inflammatory markers (CRP or ESR) is conditionally recommended 1

Non-Pharmacological Approaches

• Supervised exercise (active physical therapy) is conditionally recommended over passive interventions 1
• Land-based physical therapy is conditionally recommended over aquatic therapy 1
• Unsupervised back exercises are conditionally recommended as part of ongoing management 1
• Fall evaluation/counseling and self-management education should be incorporated into treatment 1

Special Circumstances

• For patients with advanced hip arthritis, total hip arthroplasty is strongly recommended 1
• For patients with spinal fusion or advanced spinal osteoporosis, spinal manipulation is strongly recommended against 1
• For patients with severe kyphosis, elective spinal osteotomy is conditionally recommended against 1

Treatment Target

• The primary goal should be clinical remission/inactive disease of musculoskeletal involvement 1
• Treatment targets should be individualized according to clinical manifestations 1
• Low/minimal disease activity may be an alternative treatment target when remission cannot be achieved 1