Introduction and overview

The therapeutic options for treatment of the spondyloarthropathies (SpA), especially for ankylosing spondylitis (AS), are limited. Physiotherapy is important and non-steroidal anti-inflammatory drugs (NSAIDs) provide significant symptomatic benefit, as has been shown in many studies, and recently in a six week/one year trial.1 Apart from sulfasalazine, a disease modifying antirheumatic drug, which many rheumatologists use to treat patients with peripheral arthritis and gut disease in early and in active stages of SpA, few innovative treatments have arisen in the past decades since indometacin was developed.2 The Cox-2 selective agent rofecoxib, recently introduced, causes fewer gastric ulcers but is no more effective than established NSAIDs.3 The efficacy of rofecoxib in ankylosing spondylitis (AS) has not been studied to date. Up to 20% of patients with AS do not respond well or at all to NSAIDs.4Corticosteroids are effective when applied locally intra-articularly5 but not systemically in most patients—an interesting difference from rheumatoid arthritis (RA), the pathophysiological basis of which is unclear. Interestingly, quite a few rheumatologists use methotrexate to treat AS,6though there are no randomised trials for this indication.

However, possibly positive effects of thalidomide7 and of pamidronate8 for the treatment of AS were recently reported from two open studies. Both drugs work, at least partly, by blocking the proinflammatory cytokine tumour necrosis factor α (TNFα),9 ,10 which is also the target of recently introduced new treatments for the treatment of RA11 and Crohn's disease.12 Shortly after the initial experience of our group with anti-TNF in AS13and of others in psoriatic arthritis,14 both for the first time reported in Boston at the American College of Rheumatology meeting 1999, several studies with “biological” agents acting against TNFα in SpA were reported. One study from our Belgian …