Therapeutic options for patients suffering from the more severe spondyloarthritides (SpA) have been rather limited in the last decades. Evidence is now accumulating that anti-tumour
necrosis factor (TNF)
therapy is highly effective in SpA, especially in
ankylosing spondylitis (AS) and
psoriatic arthritis (PsA). Based on the data recently published concerning more than 1000 patients with AS and PsA, this treatment seems to be even more effective than in
rheumatoid arthritis (RA). The anti-
TNFalpha agents currently available,
infliximab (
Remicade),
etanercept (
Enbrel) and
adalimumab (
Humira), are approved for the treatment of RA in the USA and Europe. The situation for SpA is different from RA because there is an unmet medical need, especially in AS, since no
therapies with disease-modifying
anti-rheumatic drugs (DMARDs) are available for severely affected patients, especially those with
spinal disease. Thus,
TNF blockers may even be considered a first-line treatment in a patient with active AS and PsA whose condition is not sufficiently controlled with non-steroidal anti-inflammatory drugs (
NSAIDs) in the case of axial disease, and
sulphasalazine or
methotrexate in the case of peripheral
arthritis. For
infliximab, a dose of 5 mg/kg is required, and intervals of between 6 and 12 weeks are necessary to constantly suppress disease activity-also a major aim for long-term treatment. The standard dosage of
etanercept is 2 x 25 mg subcutaneously per week. There are almost no studies yet on
adalimumab (standard dose in RA, 20-40 mg subcutaneously every 1-2 weeks) in SpA.
Infliximab and
etanercept are now both approved for AS in Europe. The efficacy of
etanercept was first demonstrated in PsA, and it is now approved for this indication in the USA and Europe. There is preliminary evidence that both agents also work in other SpA, such as undifferentiated SpA (uSpA). Studies should be performed to document the long-term efficacy of this treatment. There is hope that
ankylosis may be preventable, but it remains to be shown whether patients benefit from long-term anti-TNF
therapy and whether radiological progression and
ankylosis can be stopped. Severe adverse events have remained rare. Complicated
infections including
tuberculosis have been reported. These can largely be prevented by appropriate screening. As it stands now, the benefits of anti-TNF
therapy in AS seem to outweigh these shortcomings.