Long-term exposure to tumor necrosis factor inhibitor (TNFi) therapies may benefit radiographic progression in axial spondyloarthritis (axSpA), according to research results published in Arthritis & Rheumatology.

Researchers conducted a systematic review and meta-analysis examining the effect of different treatment options on radiographic progression in axSpA. Data from cohort and case-control studies published through January 16, 2019 were included; cross-sectional studies, case series, case reports, and non-human studies were excluded from the study. The primary outcome measure was the between-group difference in modified Stroke AS Spine Score (mSASSS) in ankylosing spondylitis (AS) at 2 years and ≥4 years. Other radiographic scores were secondary outcomes.

A total of 524 studies were screened, of which 24 met the following inclusion criteria: evaluation of efficacy of a therapeutic intervention, compared with placebo or other controls, in adults with axSpA (including AS and nonradiographic-axSpA [nr-axSpA]) who were followed up for at least 1 year. Therapy efficacy was determined by quantitatively scoring radiographic progression of disease. The studies examined 3 available pharmacologic treatments, including TNFis (18 studies, n=4874), nonsteroidal anti-inflammatory drugs (NSAIDs; 8 studies, n=2321), and secukinumab (1 study, n=237). Three of the 24 studies reported data for both NSAIDs and TNFis. The included studies were primarily cohort studies and open label extensions of randomized controlled trials.

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Of the TNFi studies, 17 addressed AS and 1 addressed nr-axSpA. In addition, 6 studies used a historical cohort for comparison and 2 used contemporary cohorts. Among these studies, the type of TNFi utilized was variable and included infliximab, etanercept, adalimumab, and golimumab, both alone and in combination.

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Of the 8 NSAID studies, 6 focused only on AS, 1 on early axSpA, and 1 on both AS and nr-axSpA. Six studies reported mSASSS, 1 reported the Bath AS Radiology Index (BASRI) spine score, and 1 reported the BASRI-sacroiliac joint score.

For the assessment of spinal radiographic progression with TNFi among patients with AS, most studies reported mSASSS; 1 study reported a computed tomography score of facet joints. No studies assessed spinal radiographic progression in nr-axSpA. Investigators found that spinal radiographic progression was not significantly different among biologic-naive and TNFi-treated patients at 2 years (mSASSS difference, -0.73; 95% CI, -1.52 to 0.12; I²=28%) and at ≥4 years (mSASSS difference, -2.03; 95% CI, -4.63 to 0.72; I²=63%). However, a sensitivity analysis of 6 studies with low risk for bias found a significant difference at ≥4 years (mSASSS difference, -2.17; 95% CI, -4.19 to -0.15; I²=49%).

The 6 studies that reported 2-year follow-up of mSASSS with NSAID use in AS found no significant difference between the NSAID and control groups (standardized mean difference, -0.08; 95% CI, -0.32 to 0.16; mSASSS difference, -0.30; 95% CI, -2.62 to 1.31; I²=71%). In a subgroup analysis (continuous vs on-demand NSAID use), there were no differences (P =.79) in the NSAID index high vs low and in the NSAIDs vs no NSAIDs studies. In 1 study comparing BASRI-spine for NSAID with control participants, no difference was noted (BASRI-spine difference, 0.020; 95% CI, -0.44 to 0.48). No mSASSS difference was observed in a study that reported on a subgroup of patients with nr-axSpA (mSASSS difference, 0.13; 95% CI, -0.39 to 0.65).

Results of the 1 study that assessed secukinumab did not indicate any significant difference in radiographic progression over 2 years (mean mSASSS difference, -0.34; 95% CI, -0.85 to 0.17).

“Long-term TNFi exposure might have radiographic progression benefit. No difference was seen with NSAIDs or secukinumab…at 2 years but long-term data were not available,” the researchers concluded. “Further studies should explore the effect of NSAIDs and biologics alone and in combination in patients with early axSpA.”


Karmacharya P, Duarte-Garcia A, Dubreuil M, et al. The effect of therapy on radiographic progression in axial spondyloarthritis: A systematic review and meta-analysis [published online January 20, 2020]. Arthritis Rheumatol. doi:10.1002/art41206