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Treatment of non-radiographic axial spondyloarthritis: it is only the beginning
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  1. Irene E van der Horst-Bruinsma
  1. Correspondence to Dr Irene E van der Horst-Bruinsma, Department of Rheumatology, VU University Medical Center, Room 3A-64, P.O. Box 7057, Amsterdam 1007 MB, The Netherlands; ie.vanderhorst{at}vumc.nl

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The new nomenclature used in spondyloarthritis (SpA), axial versus peripheral, as proposed by the Assessment of SpondyloArthritis international Society (ASAS) and accepted in 2009, has changed the perspective of ankylosing spondylitis (AS) and other types of spondylarthropathies.1 ,2 The axial type of SpA is subdivided in the (early) non-radiographic type (nr-axial SpA) and the radiographic type, which is equivalent to the diagnosis of AS (according to the modified New York criteria3). Instead of debating whether patients with AS do fulfil the grade of radiographic signs of sacroiliitis necessary for the diagnosis AS, the focus of interest has shifted towards the spectre of early detection of inflammation at the MRI of the pelvis and spine. The great advantage of the new nomenclature with an earlier phase of the disease is that the delay in diagnosis of SpA is shortened by years. Now the current research is directed towards the treatment options of this early stage.

The first question to be answered in the near future is whether early anti-tumor necrosis factor (TNF) treatment is effective on clinical symptoms in nr-axial SpA. The second question will be whether treatment in this early phase of the disease will sufficiently suppress inflammation in the long term. Third, and most importantly, the question arises whether this early treatment with anti-TNF has a positive benefit:risk ratio. This early and expensive treatment might diminish symptoms, but it is unclear whether it decreases or even halts the rate of radiographic progression. So far, there is no clear evidence that anti-TNF does delay this process in established AS.

In order to answer the first two questions, two interesting studies are published in Annals of Rheumatic Diseases.4 ,10

The ABILITY trial compares the efficacy of adalimumab versus placebo in nr-axial SpA …

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