Ankylosing Spondylitis — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyAnkylosing SpondylitisSCE Rheumatology

A 28-year-old man with radiographic axial spondyloarthritis (ankylosing spondylitis) has a BASDAI of 8 and spinal pain VAS of 9 cm after adequate trials of two NSAIDs at maximum tolerated dose. He has had four episodes of acute anterior uveitis in the past two years and has active ileocolonic Crohn disease. Which single advanced therapy best addresses all three disease domains?

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Correct answer: B — Adalimumab

Adalimumab is correct. He meets UK biologic eligibility (BASDAI ≥4, spinal pain VAS ≥4 cm despite two NSAIDs), and a monoclonal anti-TNF antibody is the only listed agent with established efficacy in axial disease, recurrent acute anterior uveitis and luminal Crohn disease. Etanercept treats axial disease but, as a soluble receptor fusion protein, is not licensed or effective in inflammatory bowel disease and performs poorly for uveitis, with reports of paradoxical flares. Secukinumab and ixekizumab control axial disease but IL-17 inhibition is inappropriate in active Crohn disease and evidence in uveitis is weak. Upadacitinib is effective in axial disease and Crohn disease, but evidence for recurrent uveitis is insufficient and it is a targeted synthetic, not biologic, DMARD.

Reference: NICE TA383. TNF-alpha inhibitors for treating active ankylosing spondylitis and non-radiographic axial spondyloarthritis, 2016 (reviewed 2019) — Recommendations and 'The technologies'. https://www.nice.org.uk/guidance/ta383