Dr. Ibrahim A. Al-Homood

Dr. Ibrahim AI-Homood is a consultant rheumatologist and chairman of medical specialities I department at King Fahad Medical City (KFMC), Riyadh, Saudi Arabia. He is also a director I of rheumatology fellowship program at KFMC. He is a chairman of Saudi medical license I exam council. He has several publications in scientific peer review journals

Management of non-radiographic Axial spondyloarthritis in Saudi Arabia
Axial spondyloarthritis (axSpASs) is consisting of non-radiographic axSpA (nr-axSpA) and radiographic axSpA (r-axSpA) or ankylosing spondylitis. Diagnosing r-axSpA in a typical clinical presentation is not a difficult, however; we know the presence of erosions in conventional radiography is an indication for the chronicity and should not be used as a criterion for diagnosis. Therefore, the main challenge is to establish the diagnosis in individuals with nr-axSpA that required further investigations such as MRI and HLA-B27. Nr-axSpA affects male and female equally. Patients with nr-axSpA experience significant disease burdens such as pain, morning stiffness and fatigue that similar to r-axSpA. Hence, early diagnosis is extremely important, as shorter disease duration has been found to be predictive for treatment response and for remission.
Nr-axSpA is a common disease in our society and more than 50% of our patients in different cohorts have been diagnosed with it.
Non-steroidal anti-inflammatory drugs (NSAID) could be used initially, but not all patients will response and needs a relatively long time to show the efficacy. NSAID should be used continues so, potential side effects should be taken in consideration. However, about 50% of patients with axSpA continue to have active disease after 4 weeks of NSAID treatment.
When there is inadequate response to NSAIDs or contraindications, it is very important to consider starting the approved biological therapies as soon as possible. lxekizumab, IL-17 inhibitor, results in significant improvement of patient’s symptoms, function, quality of life, and patient-reported outcome measures as early as 1-2 weeks.
Presence of different biologics that effective for management of Nr-axial SpA necessities understating the difference between these agents in form of onset of actions and the safety issues.
Shared-decision making, or involvement of the patient in treatment plan, is definitely the correct approach. Therefore, discussing the frequency of injections, onset of action and safety of the drug with the patient will enhance the compliance. Patients with nr-axial SpA have the experience of back pain with limitation in activities that affect their work and productivities, and up to 40% of patients fail to achieve satisfactory disease control with TNF inhibitors or have a contraindication to TNF inhibitors. This raised the importance of considering IL-17 inhibitors in management of nr-axial SpA.
Awareness and educational programs for nr-axial SpA are needed and require multidisciplinary teams including rheumatologists, orthopedics, spinal surgeons and family medicine physicians. Strategies like patients’ support team, education materials that directed for both physicians and patients, collaboration between centers and hospitals, and clinical studies, can be quite effective in early diagnosis and early treatment and recognizing the characters of the disease in our population.

References:

1- Rudwaleit M, et al. The early disease stage in axial spondylarthritis: results from the German Spondyloarthritis Inception Cohort. Arthritis Rheum. 2009 Mar;60(3):717-27.

3- Haibel H, et al. Efficacy of adalimumab in the treatment of axial spondylarthritis without radiographically defined sacroiliitis: results of a twelve-week randomized, double-blind, placebo-controlled trial followed by an open-label extension up to week fifty-two. Arthritis Rheum. 2008 Jul;58(7):1981-91

5- Deodhar A, et al. lxekizumab for patients with non-radiographic axial spondyloarthritis (COAST-X): a randomised, placebo-controlled trial. Lancet. 2020 Jan 4;395(10217):53-64.

2- Nikiphorou, et al. Treat to Target in Axial Spondyloarthritis. Rheum Dis Clin N Am 45 (2019) 519-535

4- Baraliakos X, et al. Efficiency of treatment with non-steroidal anti-inflammatory drugs according to current recommendations in patients with radiographic and non-radiographic axial spondyloarthritis. Rheumatology (Oxford). 2017 Jan;56(1):95-102.

Categories: Rheumatology

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