“Considering treatment options for ankylosing spondylitis”

Interviewing Professor Professor Nam Seoung Wan of Rheumatology Department at Wonju Severance Christian Hospital

Professor Nam Seoung Wan

In the autoimmune disease area, where tumor necrosis factor alpha (TNF alpha) inhibitor is leading the prescription market, various options of oral Janus kinase (JAK) inhibitors have been released so far.

 

Guidelines on treating ankylosing spondylitis and spondylarthritis in Korea and other countries have a tendency to emphasize starting the first-line treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) in patients showing symptoms.

 

And for patients not sufficiently benefiting from NSAIDs, the treatment guidelines recommend using biologics like TNF alpha inhibitor, considering the patient’s disease activity.

 

And in 2016, a guideline by Assessment of Spondyloarthritis International Society/ European League Against Rheumatism (ASAS-EULAR) recommended using TFN alpha inhibitor for first-line biologics with the most amount of clinical data accumulated, but also recommended switching to other TNF alpha inhibitor or interleukin (IL)-17 inhibitor options when showing no response to the initial option.

 

Moreover, American College of Rheumatology (ACR) and Spondyloarthritis Research and Treatment Network (SPARTAN) updated their guidelines last year and made a notable recommendation of using oral JAK inhibitor Xeljanz (tofacitinib) with an ongoing Phase III clinical study, besides using biologics like TNF alpha inhibitor (injection) and IL-17 inhibitor.

 

Also, instead of using Cosentyx (secukinumab) that received approval first, the updated recommendations mentioned of using Taltz (ixekixumab) and TNF alpha’s biosimilars approved for use in Korea recently.

 

Professor Nam Seoung Wan of Rheumatology Department at Wonju Severance Christian Hospital explained “Other than tofacitinib, various JAK inhibitors like upadacitinib have been tried on treating patients with ankylosing spondylitis.

 

Compared to other biologics, JAK inhibitors have a great advantage in medication convenience with oral administration.” However, the professor stated the treatment’s limitation is its underperforming response rate at week 12 compared to existing TNF alpha inhibitor and IL-17 inhibitor options, regardless of its better effect confirmed in head-to-head Phase II study.

 

Professor Nam stressed, “Continuous search for more treatment options in diverse biologics are encouraging for patient treatment, because each biologics have different effects on various symptoms apparent in many organs including ankylosing spondylitis, and also they bring out respective adverse reaction like risk in tuberculosis relapse.” However, the professor claimed the prescribers should be well aware of issues regarding tolerance development when using biologics for a long term.

 

Professor Nam said, “Repetitive use of biologics could possibly diminish the effect of the drug gradually due to patient’s immune response on the drugs like developing an antibody on specific medicine.

 

As for rheumatoid arthritis, there was a report claiming such tolerance is less likely to be developed when combining TNF alpha inhibitor and methotrexate (MTX).

 

But there has not been any clinical evidence reported on the benefit of using MTX combination therapy on ankylosing spondylitis.” The professor added, “However, a number of treatment strategy could be considered depending on the patient’s clinical state, as various biologic treatment options have been recently introduced to treat patients with ankylosing spondylitis.

 

And each biologics show different rate of antibody development and reaction depending on the patients.”