Intensifying treatments for axSpA driven by MD’s perspective: Study

Call for more research to optimize management of highly active disease

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by Steve Bryson PhD |

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The decision to escalate treatment for people with highly active axial spondyloarthritis (axSpA) is mainly driven by the physician’s perspective on disease activity, a real-world study has revealed.

Further research is needed to better understand these decisions and to optimize axSpA management, according to researchers in the study “Factors associated with treatment intensification in patients with axial spondyloarthritis and high disease activity in clinical practice,” which was published in the journal Rheumatology.

axSpA is a form of arthritis affecting the joints of the spine, pelvis, and chest. Ankylosing spondylitis (AS) is a subtype of axSpA characterized by inflammation of the sacroiliac joints, where the pelvis meets the base of the spine. While there is no cure for the condition, treatments such as medications, exercise, and surgery can help manage pain and prevent or delay progression.

The Ankylosing Spondylitis Disease Activity Score (ASDAS) is a standard method to assess the severity of disease activity and measure different features of the condition, including back pain, peripheral pain or swelling, morning stiffness, biomarkers for inflammation, and a patient’s perception of disease activity.

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Goal of treatment is sustained inactive disease or low disease activity

The goal of treatment is to achieve sustained inactive disease, with ASDAS scores below 1.3, or low disease activity, defined by scores below 2.1. More intense treatments are recommended when the disease activity is high, with scores above 2.1. This escalation of treatment may include higher or more frequent doses of medication or switching to or adding new drugs.

Still, other factors, such as the views of patients and clinicians, may also influence a move to more intensive treatment.

In this report, researchers in the Netherlands investigated which factors were associated with treatment intensification in a clinical setting in axSpA patients with high disease activity.

A group of 121 with ASDAS scores at or above 2.1 (mean 2.9) was followed, with a mean age of 50.4 years, of whom about half (53.7%) were women. Participants had been experiencing axSpA symptoms for a mean of 20 years.

Most participants (61.2%) received nonsteroidal anti-inflammatory drugs. Other common medications (57.9%) included biological disease-modifying anti-rheumatic drugs (bDMARDs) such as TNF inhibitors, which block the key inflammatory mediator TNF.

Treatment was most often intensified with a switch to another treatment within the same class or the addition of a new drug, primarily a bDMARD. Among those taking bDMARDs, switching medications frequently involved another bDMARD.

A patient-centered perspective considered ASDAS scores, age, sex, education, and patient-reported disease impact, as assessed with the Assessment of SpondyloArthritis International Society Health Index (ASAS HI).

A physician-centered perspective included the patient’s perspective combined with the Physician Global Assessment (PhGA) of disease activity, peripheral symptoms, and skin involvement measured by the body surface area affected.

Adjusted statistical analysis found that higher ASDAS scores were significantly associated with treatment intensification in the patient-centered model. However, when the physician perspective was introduced, this association weakened. Instead, physician-based factors were now dominant, such as PhGA and peripheral symptom assessments.

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Link found between physician assessment and disease activity scores

There was a significant relationship between PhGA and ASDAS scores, “indicating that the association between PhGA and [treatment intensification] depended on the ASDAS,” the researchers wrote. In particular, higher (worse) PhGA scores were significantly associated with a switch to more intensive treatments in those with the highest ASDAS scores (at or above 2.75).

A similar trend was found among patients with very high disease activity, with an ASDAS score greater than 3.5. Still, the researchers noted there were too few of these patients to analyze statistically.

By contrast, as assessed by patients via ASAS HI, disease impact was not associated with treatment intensification in any of the models. Education, sex, and body surface area of skin involvement also were not associated with treatment intensification.

Patients receiving either bDMARDs or targeted synthetic DMARDs (tsDMARDs), such as those blocking the action of JAK, enzymes that regulate inflammation in AS, were less likely to receive more intensive treatment than those not on these medications (29% vs. 40%). No link was found between the number of previous biological/targeted synthetic DMARDs and treatment intensification.

In a sensitivity analysis, the results remained the same when disease activity was assessed using a different tool, namely the acceptable symptom state according to the physician or patient.

“The decision to intensify treatment is mainly associated with physician-centered factors, and not with patient-centered factors or ASDAS,” the researchers concluded. “Further research is needed to better understand these treatment decisions, and ultimately optimize axSpA disease management.”