The TNF inhibitors certolizumab pegol (Cimzia) and infliximab (Remicade, Remsima, Inflectra) can now be prescribed on the NHS to treat patients with severe active ankylosing spondylitis whose condition has responded inadequately to, or who are unable to tolerate, NSAIDs.
NICE technology appraisal TA383
Where more than one TNF inhibitor is considered suitable, the least expensive should be prescribed. Patients already on infliximab should be switched to the least expensive brand once appropriate. Those beginning infliximab treatment following the publication of this guidance should be started on the least expensive brand.
Adalimumab, certolizumab pegol and etanercept are also recommended as options for treating severe non-radiographic axial spondyloarthritis when NSAIDs have already been tried, unsuccessfully, or when they cannot be tolerated.
In both conditions, the response to treatment with a TNF inhibitor should be assessed after 12 weeks. Treatment should be continued only if there is a clear response, defined as:
- a reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score to 50% of the pre-treatment value, or by 2 or more units and
- a reduction in the spinal pain visual analogue scale (VAS) by at least 2cm
Healthcare professionals should note that physical, sensory or learning disabilities as well as communication difficulties may affect these scores and appropriate adjustments should be made.
If patients cannot tolerate or fail to respond to a TNF inhibitor, or stop responding after an initial response, another TNF inhibitor should be tried.