Can Axial Spondyloarthritis (AxSpA) go into remission?

Can Axial Spondyloarthritis Go Into Remission?

Yes, axial spondyloarthritis (AxSpA) can achieve remission, though this occurs in a minority of patients—most will achieve sustained low disease activity as their realistic treatment target. 1, 2

Understanding Remission in AxSpA

Remission is defined as inactive disease with ASDAS (Ankylosing Spondylitis Disease Activity Score) < 1.3, absence of extra-articular manifestations, normal inflammatory markers, and no radiographic progression. 3 However, the Pan American League of Associations for Rheumatology (PANLAR) and other major guidelines acknowledge that while remission is the preferred therapeutic target, most patients will only achieve sustained low disease activity during long-term treatment, which should be considered an acceptable alternative target. 1, 2

Remission Rates with Treatment

With Biologic Therapy

• In early AxSpA treated with certolizumab pegol, approximately 44% of patients achieved sustained clinical remission (ASDAS < 1.3) after 48 weeks of treatment. 4
• This included 42.8% of patients with radiographic axSpA and 45.3% with non-radiographic axSpA. 4
• The key factor is early disease (< 5 years symptom duration), suggesting that earlier intervention improves remission rates. 4

Maintaining Remission

Sustained remission is challenging to maintain, and abrupt discontinuation of biologic DMARDs leads to flares in most patients. 1 The evidence shows:

• After achieving remission on TNF inhibitors, approximately 21% of patients lose remission status and 16% experience disease flares during follow-up. 5
• Among patients who discontinued TNF inhibitor therapy after achieving low disease activity, 74% experienced increased disease activity after a mean of 14 weeks and required treatment restart. 6
• When treatment was restarted, low disease activity was regained in all patients after a mean of 7 weeks. 6

Predictors of Sustained Remission

Residual inflammatory activity predicts loss of remission. The following factors are associated with disease reactivation: 5

• Elevated ESR (> 15 mm/hr) during the remission period (OR 2.90) 5
• Continuous NSAID use during remission (OR 4.05) 5
• ASDAS-CRP ≥ 0.8 during the remission period 5
• Higher baseline CRP and ESR levels 6

These markers indicate that complete suppression of inflammation is critical for maintaining remission.

Treatment Strategy for Achieving Remission

A target-based treatment strategy using ASDAS and inflammatory markers (CRP/ESR) should guide therapy, with monitoring every 3-4 months when initiating new treatment. 1

Pharmacological Approach

1. Start with NSAIDs at maximum dose for symptomatic patients 1
2. If inadequate response after 1 month, initiate biologic DMARDs (TNF inhibitor or IL-17 inhibitor) 1
3. Combine pharmacological treatment with active, supervised physical therapy throughout all disease stages 1, 2

Tapering Considerations

If sustained remission is achieved for at least 12 months on biologic DMARDs, tapering (dose reduction or interval extension) can be conditionally considered, but abrupt discontinuation is strongly recommended against. 1 This is because:

• Abrupt discontinuation leads to flares in the majority of patients 1
• Not all patients regain their former remission status after resuming treatment 1
• Gradual tapering is more successful in maintaining disease control 1

Clinical Reality

While remission is achievable, particularly in early disease with aggressive treatment, sustained low disease activity is the more realistic long-term goal for most patients with AxSpA. 1, 2, 7 This represents a patient and provider acceptable disease state that maintains physical function and quality of life while minimizing disease progression. 7

The distinction matters clinically: only 14 patients (22%) in one study maintained low disease activity longer than 6 months without relapse after stopping TNF inhibitors, while 83% of patients initially achieved low disease activity with treatment. 6 This underscores that while treatment-induced remission/low disease activity is common, maintaining it off therapy remains challenging for the majority.