Reports From National Arthritis Meeting

Dr. Shiel Gives Perspectives Of Interest On Ankylosing Spondylitis and Psoriatic Arthritis From
2004 Annual Scientific Meeting Of The American College Of Rheumatology

Introduction

Ankylosing spondylitis is a form of chronic inflammation of the spine and the sacroiliac joints. The sacroiliac joints are located in the low back where the sacrum (the bone directly above the tailbone) meets the iliac bones (bones on either side of the upper buttocks). Chronic inflammation in these areas causes pain and stiffness in and around the spine. Over time, chronic spinal inflammation (spondylitis) can lead to a complete cementing together (fusion) of the vertebrae, a process called ankylosis. Ankylosis can lead to total loss of mobility of the spine.

Psoriatic arthritis is a chronic disease that is characterized by inflammation of the skin (psoriasis) and joints (arthritis ). Psoriasis is a common skin condition that affects 2% of the Caucasian population in the United States. It is often characterized by patchy, raised, red areas of skin inflammation with scaling. Psoriasis often affects the tips of the elbows and knees, the scalp, the navel, and around the genital areas or anus. Approximately 10% of patients who have psoriasis also develop an associated inflammation of their joints. Patients who have arthritis and psoriasis are diagnosed as having psoriatic arthritis.

Ankylosing spondylitis and psoriatic arthritis are genetically and clinically related diseases. I will, therefore, report on papers presented at this meeting related to both of the diseases here.

Medications

Let me start by reporting on a large symposium that was given on ankylosing spondylitis. During this marvelous talk, three world's experts in the field of ankylosing spondylitis made several major points. There is an early, under diagnosed stage of spondylitis that occurs before plain x-ray testing can detect classic changes. Patients who are treated earlier respond better to treatments. Current disease-modifying drugs, such as methotrexate, sulfasalazine, and Arava, which can be effective for joint inflammation of joints away from the spine, are NOT effective for spinal inflammation. If nonsteroidal antiinflammatory drugs (NSAIDs) are not effective in a patient whose condition is dominated by spinal inflammation (and 50% do respond), then biologic medications that inhibit tumor necrosis factor (TNF inhibitors) are indicated. All TNF inhibitors, including Remicade, Enbrel, and Humira are effective in treating ankylosing spondylitis. The improvement that results for TNF inhibition is sustained during years of treatment. If the TNF inhibitors are discontinued, for whatever reason, relapse of disease occurs in virtually all patients in a year. If TNF inhibitor is then resumed, it is typically effective.

Dr. Shiel's Perspective: These are critically important concepts that are now clear. These speakers went to great length to emphasize key issues in the treatment of ankylosing spondylitis. The entire treatment methods have now changed!

Enbrel and Remicade were reported effective in treating ankylosing spondylitis as manifest by improvements in spinal MRI testing.

Dr. Shiel's Perspective: Enbrel has been approved for ankylosing spondylitis treatment within the past year. Remicade will be soon.

Remicade (infliximab) was reported as safe and effective in psoriasis, psoriatic arthritis, and ankylosing spondylitis.

Dr. Shiel's Perspective: Actually, rheumatologists have been using the drug for these patients for some time because of other preliminary positive reports in these conditions. It is good to have the support of this further long-term follow-up research.

Enbrel for ankylosing spondylitis was reported to have sustained benefit and safety for at least 24 months.

Dr. Shiel's Perspective: Enbrel appears to be a safe and effective treatment for ankylosing spondylitis. The only reason it is only 2 years is because that is how long the study has been running at this point.

Remicade's beneficial effect in treating ankylosing spondylitis was shown to be sustained over a 2 year study period.

Dr. Shiel's Perspective: This is a type of study that demonstrates that not only does Remicade work for spondylitis patients, but its benefits are longterm.

Arava (leflunomide) was significantly effective in treating BOTH the skin inflammation (psoriasis) and the arthritis in patients with psoriatic arthritis.