Inflammation, new bone formation and treatment options in axial spondyloarthritis
- Medical Department I, Rheumatology, Campus Benjamin Franklin, Charité, Berlin, Germany
- Correspondence to Professor Joachim Sieper, Medical Department I, Rheumatology, Campus Benjamin Franklin, Charité, Hindenburgdamm 30, 12200 Berlin, Germany;
- Received 24 March 2014
- Accepted 17 April 2014
- Published Online First 8 May 2014
How and whether ankylosis is connected with inflammation has been discussed for a long time.1 There are two major reasons for this debate. First, no effective anti-inflammatory treatment was available in the past for ankylosing spondylitis (AS) as salicylates, which have been used to treat inflammatory rheumatic diseases for over 100 years, were not effective. However, the first non-steroidal anti-inflammatory drug (NSAID), phenylbutazone, was introduced into clinical practice around 1949 and was highly effective in patients with active AS. It was followed in subsequent decades by many other NSAIDs. The good therapeutic efficacy of NSAIDs was used to differentiate AS from degenerative causes of back pain2 due to their good anti-inflammatory properties. Nonetheless, NSAIDs for the treatment of AS are still often regarded incorrectly by the public as just ‘painkillers’ which should be avoided.3 Furthermore, conventional anti-inflammatory disease-modifying anti-rheumatic drugs (DMARDs) which are highly effective in many chronic rheumatic diseases such as rheumatoid arthritis, are not effective in AS,4 similarly to low or moderate doses of glucocorticoids, which also show lack of efficacy.5 All this contributed to the assumption that inflammation does not play a major role in AS, which was believed to be rather dominated by new bone formation and ankylosis.
Approximately 14 years ago, the dramatic efficacy of tumour necrosis factor (TNF) blockers was demonstrated in patients with active AS.6 The debate on the interaction between inflammation and new bone formation was fuelled again by the finding that treatment of patients with active AS with TNF blockers for 2 years, despite the good effect on signs and symptoms, C-reactive protein (CRP) and inflammation as detected by MRI, did not prevent new bone formation in the spine.7 This is the second major reason for the ongoing discussion on the association between inflammation and new bone …