What's the best way to slow down the progression of axial spondyloarthritis (axSpA)?

Slowing Progression of Axial Spondyloarthritis

To slow disease progression in axial spondyloarthritis, initiate biologic DMARDs (TNF inhibitors or IL-17 inhibitors) when NSAIDs fail to control disease activity, as these are the only therapies proven to reduce structural damage and improve long-term outcomes. 1

Step 1: Start with NSAIDs for Symptom Control

• Begin treatment with continuous NSAIDs at maximum tolerated doses as first-line therapy for active disease 1
• NSAIDs provide excellent symptom relief (70-80% of patients respond) but their role in preventing radiographic progression remains controversial 2, 3
• Some evidence suggests continuous NSAID use may retard radiographic spinal progression, particularly in patients with elevated CRP, though this requires confirmation 3
• Consider NSAID failure after 1 month of continuous use (trial at least two different NSAIDs for 15 days each) 1, 4
• Use selective COX-2 inhibitors when available in patients at high cardiovascular or gastrointestinal risk 1, 4

Step 2: Escalate to Biologic DMARDs or JAK Inhibitors

When NSAIDs provide inadequate response, biologic DMARDs are strongly recommended as they are the only proven disease-modifying agents for axial disease. 1

First-Line Biologic Options:

• TNF inhibitors (adalimumab, etanercept, golimumab, certolizumab pegol, infliximab) are preferred initial biologics with extensive long-term safety data 1
• IL-17 inhibitors (secukinumab, ixekizumab) are equally appropriate first-line options with comparable efficacy 1
• Clinical trials show ASAS20 improvement in 58-64% with anti-TNF agents versus 19-38% with placebo 5
• IL-17 inhibitors achieve ASAS20 response in 48-61% versus 18-29% with placebo 5
• Both TNF and IL-17 inhibitors reduce radiographic progression of structural damage 5

Second-Line Options:

• JAK inhibitors (tofacitinib, upadacitinib) should be reserved for when TNF and IL-17 inhibitors are contraindicated or unavailable 1
• JAK inhibitors achieve ASAS20 response in 52-56% versus 26-29% with placebo 5
• In patients ≥65 years with smoking history or cardiovascular risk factors, use JAK inhibitors only if no suitable alternatives exist due to increased cardiovascular and malignancy risks 1

Step 3: What NOT to Use for Axial Disease

Conventional synthetic DMARDs (methotrexate, leflunomide) are strongly recommended AGAINST for purely axial involvement as they show no benefit over placebo. 1

• Sulfasalazine may be used only if active peripheral arthritis is present, but provides minimal to no benefit for axial symptoms 1
• Long-term systemic glucocorticoids are strongly recommended against due to risks outweighing benefits 1

Step 4: Treatment Switching Strategy

If primary failure occurs (inadequate response after 3 months):

• Switch to a biologic with a different mechanism of action 1

If secondary failure occurs (loss of response):

• Switch to another biologic with the same or different mechanism of action 1

Step 5: Combine with Physical Therapy

• Always combine pharmacological treatment with active physical therapy and supervised exercise programs 1
• Exercise improves health-related quality of life and functional parameters 2
• Physical therapy should be managed by experts in physical medicine and rehabilitation 1

Monitoring Disease Activity

• Monitor at regular intervals using ASDAS and/or BASDAI with CRP and/or ESR 1
• Routine MRI or radiographic studies for follow-up are strongly recommended against 1
• Target sustained low disease activity or remission as treatment goals 1

Critical Pitfall to Avoid

The most common error is continuing NSAIDs alone or adding conventional DMARDs when NSAIDs fail for axial disease. This delays the only effective disease-modifying therapy (biologics) and allows continued structural progression. 1 Escalate to biologics promptly after NSAID failure to prevent irreversible spinal damage and preserve quality of life.