Effectiveness of lymphocytapheresis in a patient with ankylosing spondylitis

Therapy of ankylosing spondylitis--a review. Part I: Conventional medical treatment and surgical therapy

The main outcome parameters in AS and other SpA are pain, disease activity, function, spinal mobility, and structural progression. There are several treatment options, which differ, depending on the localization and severity of the manifestation and the degree of structural changes already present. There is a basic role for physiotherapy to improve and maintain spinal mobility and function and prevent handicap. The basis for drug therapy in AS is NSAIDs, which may also have an influence on structural progression. DMARDs are mainly used in cases with peripheral arthritis. Corticosteroids have a clear role for intra-articular therapy, while the role for systemic use is, in contrast to RA, mainly reserved for subgroups. It is largely unclear whether long-term spinal progression can be prevented by conventional drug therapy. Treatment with biologics such as anti-TNF-alpha therapy is discussed in Part 2 of this review. To be published in the next issue of the Scandinavian Journal of Rheumatology. Surgical treatment of the spine is indicated in cases of severe instability pain, in cases of deformity endangering the patient in daily life by the limited range of vision, and in patients with neurological deficiency. AS-specific problems are spinal fractures and atlantoaxial instability, which need careful management including surgery. Joint replacement therapy is established and beneficial for AS-disturbed joints of the hip and knee.

Anti-TNF agents for the treatment of spondyloarthropathies

For the treatment of spondyloarthropathies (SpA), therapeutic options using disease-modifying drugs are rather limited compared to other inflammatory rheumatic diseases such as rheumatoid arthritis (RA). This is especially true for the spinal symptoms of the spondyloarthropathies, of which ankylosing spondylitis (AS) is the prototype. New TNF-alpha blockers have been proven highly effective in improving the spinal symptoms and extra-spinal manifestations of SpA. Convincing data in the form of placebo-controlled trials are already available for AS and psoriatic arthritis (PsA). However, limited data suggests that TNF-alpha blockers might be similarly effective in other spondylolarthropathies. Side effects, mainly infections and allergic reactions, occur similar to those observed in RA treatment. Currently, there is no reason to combine TNF-alpha blockers with other disease-modifying anti-rheumatic drugs (DMARDs) for the treatment of AS and other SpA, as these DMARDs are not effective. Thus, TNF-alpha blockers seem to be a major breakthrough in the treatment of SpA. The patients who are primary candidates for such treatments are yet to be defined, particularly in light of the high costs and unknown long-term side effects involved. Furthermore, future studies need to show whether these biologicals not only suppress inflammation but also prevent long-term bony damage.

Leukocytapheresis for rheumatic disease

Leukocytapheresis (LCAP) is an apheresis technique for depleting pathogenic leukocytes from the circulating blood to improve the condition of the patient. LCAP sensu lato has been applied for the treatment of various rheumatic diseases: other treatments include thoracic duct drainage, photopheresis, centrifugal LCAP, granulocytapheresis (GCAP) and filtration LCAP. Among these modalities, GCAP and filtration LCAP are most commonly used in Japan for two reasons; the equipment and procedure are simple and practical and adverse events are rare and minor. In this article, LCAP, in particular filtration LCAP, for the treatment of rheumatic diseases is reviewed.

Therapy of ankylosing spondylitis and other spondyloarthritides: established medical treatment, anti-TNF-alpha therapy and other novel approaches

Therapeutic options for patients with more severe forms of spondyloarthritis (SpA) have been rather limited in recent decades. There is accumulating evidence that anti-tumor-necrosis-factor (anti-TNF) therapy is highly effective in SpA, especially in ankylosing spondylitis and psoriatic arthritis. The major anti-TNF-alpha agents currently available, infliximab (Remicade(R)) and etanercept (Enbrel(R)), are approved for the treatment of rheumatoid arthritis (RA) in many countries. In ankylosing spondylitis there is an unmet medical need, since there are almost no disease-modifying antirheumatic drugs (DMARDs) available for severely affected patients, especially those with spinal manifestations. Judging from recent data from more than 300 patients with SpA, anti-TNF therapy seems to be even more effective in SpA than in rheumatoid arthritis. However, it remains to be shown whether patients benefit from long-term treatment, whether radiological progression and ankylosis can be stopped and whether long-term biologic therapy is safe.