Understanding Non-Radiographic Axial Spondyloarthritis - Episode 17

Treatment of Newly Diagnosed nr-axSpA

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Transcript: Sergio Schwartzman, MD: As we embark on therapies for nonradiographic axial spondyloarthritis, the first question is, what nonpharmacological treatments should patients include in their treatment plan? Overwhelmingly, I believe that the most important nonpharmacological therapy is to educate your patient. I’m not talking about educating other rheumatologists.

But it’s impressive to me how many times I will see patients with rheumatic diseases in general, including nonradiographic axial spondyloarthritis, being seen by other rheumatologists who really don’t understand their disease process, who don’t even recognize that it’s not like any other illness that they’ve had before, that it is going to be a chronic illness. This isn’t like the flu or a urinary tract infection that you are going to get past. This is something you are going to have the rest of your life.

All 4 of us have touched on the comorbidities and cold manifestations of this disease. Educating our patients in terms of the possibility of those things occurring is a critically therapeutic intervention because they will be the first to recognize that they have a pink eye that’s not going away, despite the drops the ophthalmologist gave them. They’re going to know because we’ve told them that uveitis is 1 of the potential complications of this illness.

That would be my first step. The other steps are relatively intuitive. No. 1, I insist on my patients stretching every morning. I tell them the first 20 to 30 minutes in the morning are your time to stretch. I insist on eating well. It isn’t an “anti-inflammatory diet.” It’s just eating well and not going to McDonald’s. I insist on them maintaining good weight, and I think that’s important as well.

Those issues—stretching, exercise, appropriate diet, maintenance of weight—are the most critical nonpharmacological interventions. I can’t overemphasize the point about educating your patient about the disease. With that, Atul, the next question is for a newly diagnosed patient with nonradiographic axial spondyloarthritis. What factors do you utilize to decide on treatment?

Atul Deodhar, MD, MRCP: That’s an important point. I think Tiffany mentioned this very early on, that having a diagnosis is a big relief to the patient when they have gone from pillar to post trying to find what’s wrong with them. You already have touched on education. It’s very important to tell them that this is a chronic disease and to reassure them that not everybody who gets this disease is going to get bamboo spine.

In fact, we have very promising drugs that will probably prevent this. I say probably because we don’t really have any definitive answer, but finding the patients and improving their quality of life with our treatment is something that we can definitely achieve. One thing which I also tell patients, apart from your other insistence, is to stop smoking. One of the things we know progresses a person from nonradiographic to radiographic—and also within radiographic to get new bone formation—is smoking.

At that stage of nonradiographic spondyloarthritis, the treatment plan is purely dependent on the symptoms they have. Initially, I would definitely somebody with physical therapy, as you already have mentioned, and that continues throughout their lifetime. The nonsteroidal anti-inflammatory drugs will be the first pharmacological treatment that I would start almost all the patients on, unless there is a complete contraindication for that. That would be rare, but it may happen in some patients.

The 2019 ACR [American College of Radiology] Appropriateness Criteria, SAA [Spondylitis Association of America], and SPARTAN [Spondyloarthritis Research and Treatment Network] treatment guidelines for axial spondyloarthritis have recently been published, and they have a very nice treatment plan and algorithm in regard to the questions, “What do you start first? Where do you go next? What do you assess?” It specifically states that the actions you take on the treatment plan depend on getting together with the patient in deciding whether the signs and symptoms that the person has are because of the active disease.

We’ll come to biologics probably later in this discussion. At that time, of course, you need to look at whether there is an objective evidence of inflammation. For the first part—the physical therapy, nonsteroidal anti-inflammatory drugs, lifestyle changes, patient education—these should be uniform in all patients with nonradiographic axial spondyloarthritis.

Sergio Schwartzman, MD: Tiffany, give us a real-world example. You’ve given us your journey, and we touched on therapies. But specifically, where are you now having gone through this journey? How are you being managed? Has the current therapy that you have been on changed your quality of life?

Tiffany Westrich-Robertson: Well, the current therapy that I’ve been on has drastically changed the quality of my life. As I had mentioned previously, the original biologic agent I was on was indicated for rheumatoid arthritis. As a result, I was on that biologic when I progressed. It got so bad that I couldn’t get out of bed. Being on the right biologic that is indicated for spondyloarthritis has been integral to my personal disease management.

I also try to eat not anti-inflammatory, as you stated, but a diet that eliminates as much processed food, so my body isn’t expending energy breaking that down. I exercise as I am able, and that together has really helped the quality of life. I do have to add that in terms of the flexibility of the workplace, I can’t say it enough how much it’s needed to be able to sleep. If I have the issue of stiffness in the morning, just having that flexible environment helps my productivity.

Sergio Schwartzman, MD: Thank you.

Tiffany Westrich-Robertson: As far as my treatment protocol and how things have changed, the first several years I was on Orencia [abatacept], which was indicated for rheumatoid arthritis. I felt somewhat controlled as far as pain levels and fatigue and some of the other symptoms that are associated with these autoimmune diseases. However, I was progressively feeling more impact in my spine, my neck, my lower back in particular, and my heel. We talked about that earlier.

Those areas were becoming much more aggressive. When I switched, when the new rheumatologists had identified the potential for nonradiographic axial spondyloarthritis, he was performing the clinical trial for Cimzia [certolizumab pegol] at that time for the disease. He has suggested that he go ahead and prescribe that for me and see how I respond. I did the dosing, the double dose and then the next 1.

I started noticing a change almost immediately after those first 3 weeks. The biggest difference was that I was not staying in bed as long in the morning. That’s huge, so I still was experiencing the stiffness, but I was not having to tilt my pelvis forward to walk. It sounds simple, but that’s a big deal when you have to change the way you walk.

It took about 3 to 6 months on the therapy to really start feeling, “Wow, this has drastically improved my quality of life.” Prior to that, I couldn’t go to the grocery store or even a retail store by myself because I never knew if I was going to have to leave to go sit in the car while somebody else paid. I just didn’t know how long I could stand. I’ve been able to do more of that now and been able to facilitate my day much better, much easier. I still have disease activity, but it is manageable now.

Transcript Edited for Clarity