Successful use of infliximab in a patient with treatment resistant spondyloarthropathy related uveitis

Biologics for the treatment of noninfectious uveitis: current concepts and emerging therapeutics

PURPOSE OF REVIEW

There is mounting evidence supporting the use of biologic therapeutics for the management of noninfectious uveitis (NIU). This review highlights: biologics with documented efficacy in NIU; agents with ongoing evaluation for efficacy in uveitis; and therapeutics for which investigation for efficacy in NIU is warranted.

RECENT FINDINGS

The tumor necrosis factor-alpha (TNF-α) inhibitor adalimumab has recently gained approval by the Food and Drug Administration for the treatment of noninfectious intermediate, posterior, and panuveitis. There is mounting evidence supporting the use of tocilizumab and rituximab in NIU. There is developing interest in evaluating the interleukin (IL)-23 inhibitors for efficacy in NIU.

SUMMARY

The TNF-α inhibitors adalimumab and infliximab have the greatest body of data supporting their use in NIU. These agents are considered second-line therapy for most forms of NIU but may be considered first-line therapy for uveitis associated with Behçet's disease and juvenile idiopathic arthritis. The B-cell inhibitor rituximab and the IL-6 inhibitor tocilizumab also have documented efficacy in NIU. Tocilizumab and interferon therapy may be particularly efficacious in the management of uveitic macular edema. The IL-23 inhibitors and janus kinase inhibitors are agents whose efficacy in NIU will likely be determined in the near future.

Adalimumab Significantly Reduces the Recurrence Rate of Anterior Uveitis in Patients with Ankylosing Spondylitis

Objective.

To investigate whether use of adalimumab decreases the frequency of attacks of anterior uveitis (AU) in patients with ankylosing spondylitis (AS).

Methods.

Consecutive patients with AS, visiting an outpatient clinic and treated for at least 12 weeks with adalimumab, were enrolled. The number of attacks of AU in the year before start and during treatment were assessed by patient history and ophthalmological controls.

Results.

In the 77 patients a total of 52 AU attacks occurred in the year before baseline (68 attacks per 100 patient-yrs), whereas during adalimumab treatment 19 attacks were seen (14 per 100 patient-yrs; reduction rate 80%). Twenty-six patients with AU in the year before start of adalimumab treatment had recurrent attacks, with a median number of 2.0 AU attacks per year [interquartile range (IQR) 1.00–3.00], whereas during treatment this decreased to 10 patients with a median number of 0.56 attacks per year (IQR 0.30–0.75). Hence, the number of attacks per year decreased by 72% (p = 0.000).

Conclusion.

In patients with AS, a significant reduction in the number of AU attacks, as well as in the number of attacks per patient, was observed during adalimumab treatment.

Update on the use of systemic biologic agents in the treatment of noninfectious uveitis

Uveitis is one of the leading causes of blindness worldwide. Noninfectious uveitis may be associated with other systemic conditions, such as human leukocyte antigen B27-related spondyloarthropathies, inflammatory bowel disease, juvenile idiopathic arthritis, Behçet’s disease, and sarcoidosis. Conventional therapy with corticosteroids and immunosuppressive agents (such as methotrexate, azathioprine, mycophenolate mofetil, and cyclosporine) may not be sufficient to control ocular inflammation or prevent non-ophthalmic complications in refractory patients. Off-label use of biologic response modifiers has been studied as primary and secondary therapeutic agents. They are very useful when conventional immunosuppressive therapy has failed or has been poorly tolerated, or to treat concomitant ophthalmic and systemic inflammation that might benefit from these medications. Biologic therapy, primarily infliximab, and adalimumab, have been shown to be rapidly effective for the treatment of various subtypes of refractory uveitis and retinal vasculitis, especially Behçet’s disease-related eye conditions and the uveitis associated with juvenile idiopathic arthritis. Other agents such as golimumab, abatacept, canakinumab, gevokizumab, tocilizumab, and alemtuzumab may have great future promise for the treatment of uveitis. It has been shown that with proper monitoring, biologic therapy can significantly improve quality of life in patients with uveitis, particularly those with concurrent systemic symptoms. However, given high cost as well as the limited long-term safety data, we do not routinely recommend biologics as first-line therapy for noninfectious uveitis in most patients. These agents should be used with caution by experienced clinicians. The present work aims to provide a broad and updated review of the current and in-development systemic biologic agents for the treatment of noninfectious uveitis.

Management of ankylosing spondylitis with infliximab

Ankylosing spondylitis (AS) is a systemic inflammatory rheumatic disease responsible for back pain, stiffness and progressive loss of functional capacity with limited therapeutic options. Regular physical exercises together with the use of nonsteroidal antiinflammatory drugs are the two recognized treatment options in AS. Infliximab is a chimeric anti-tumor necrosis factor-α monoclonal antibody that has been demonstrated to be highly effective in the treatment of AS, providing clinical amelioration at both axial and peripheral skeleton. Infliximab also improves quality of life, function, biological parameters (acute phase reactants) and inflammatory lesions of the spine as detected by magnetic resonance imaging. It is given at a 5 mg/kg dosage, as an infusion at weeks 0, 2, 6, and every 6 to 8 weeks after. Open-label and placebo-controlled trials have well demonstrated its high level of efficacy, with an improvement of the disease activity of at least 50% in 60%-80% of patients. In a large placebo-controlled trial, Assessment in Ankylosing Spondylitis Response Criteria (ASAS20) responders were observed in 61.2% of patients receiving infliximab compared to 19.2% of patients under placebo. Long-term efficacy is maintained when infliximab is administered every 6-8 weeks. Consensus international guidelines for the initiation and the use of this expensive treatment are available. Some questions remain, including the long-term safety, in particular the risk of lymphoma, and the potential influence of infliximab on radiological progression which is not currently demonstrated. Despite these concerns, infliximab has revolutionized the management of AS and represents a considerable therapeutic advancement in this disabling disease.

Tumor necrosis factor antagonists: preliminary evidence for an emerging approach in the treatment of ocular inflammation

The anti-tumor necrosis factor (TNF) monoclonal antibody infliximab and the soluble TNF receptor etanercept inhibit the pleiotropic actions of TNF and are widely used for the treatment of rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), spondyloarthropathies (SpA), Crohn's disease, and psoriasis with an acceptable safety profile. A pathogenetic role of TNF in ocular inflammatory conditions has recently emerged from small trials reporting preliminary results on the efficacy of these agents in patients with noninfectious uveitis, regardless of the origin of the disease. The authors review the published experience, derived mostly from investigator-sponsored trials and uncontrolled case series, on the use of TNF antagonists in approximately 280 patients with various ocular conditions who were inadequately controlled on currently available therapy. These reports suggest that TNF antagonists, mainly infliximab, which may have better efficacy than etanercept, are useful in the treatment of ocular inflammation associated with Adamantiades-Behçet's disease, RA, JIA, SpA, Crohn's, sarcoidosis, and Graves' disease ophthalmopathy. Infliximab was also beneficial in small numbers of patients with idiopathic uveitis or scleritis, birdshot retinochoroiditis, uveitic and diabetic cystoid macular edema, and age-related macular degeneration. The currently available data are nonrandomized and thus preliminary, providing the foundation and justification for randomized trials to assess efficacy and safety. Until such results are available, knowledge regarding the use of anti-TNF regimens in ophthalmology is incomplete. However, the preliminary evidence points to a growing optimism for targeting TNF in patients with ocular inflammation.

Infliximab for the treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) had previously been considered as a chronic disease with little therapeutic options. Non-steroidal anti-inflammatory drugs (NSAIDs) and regular physiotherapy were the only treatment modalities available for patients with AS. The introduction of biologics into clinical practice has substantially broadened the therapeutic armamentarium in AS patients who are refractory to NSAIDs. Remicade (infliximab; Centocor, Inc., USA), a chimeric monoclonal antibody, targets TNF-alpha, and by inhibition of this proinflammatory cytokine, exerts strong clinical improvement of signs and symptoms of AS. In AS, infliximab 5 mg/kg body weight is usually given as an infusion at weeks 0, 2 and 6, and every 6 - 8 weeks thereafter. An improvement of the disease activity by at least 50% is seen in as many as 50% of AS patients treated with infliximab in addition to NSAIDs. Back pain and also peripheral manifestations, such as enthesitic sites and arthritis, improve, and quality of life significantly increases. In addition, elevated acute phase reactants return to normal or low levels, and active inflammatory lesions of the spine as detected by magnetic resonance imaging substantially regress during treatment with infliximab. Clinical improvement occurs during the first 2 weeks of treatment and the clinical response to infliximab, if given continuously, is sustained and long-lasting as follow-up data of ongoing studies show. The short-term benefit/risk ratio of infliximab is clearly in favour of the drug, and it is estimated that at present up to 30% of patients with active AS are in need of this kind of effective treatment.

Immunomodulatory effects of etanercept on peripheral joint synovitis in the spondylarthropathies

OBJECTIVE

Because different tumor necrosis factor alpha (TNFalpha) blockers may have distinct immunomodulatory effects on specific disease manifestations, the present study was carried out to investigate the immunomodulating effects of etanercept on peripheral synovitis in the spondylarthropathies (SpA).

METHODS

Peripheral joint disease was assessed clinically, histologically, and radiologically in a prospective 2-year study of 20 patients with SpA treated with etanercept. Synovial tissue biopsy samples obtained at weeks 0, 12, and 52 were analyzed by histology and immunohistochemistry for the extent of inflammation, changes to tissue architecture, and matrix degradation. Serum levels of myeloid-related protein 8 (MRP-8)/MRP-14, matrix metalloproteinase 3 (MMP-3), and cartilage oligomeric matrix protein (COMP) were determined by enzyme-linked immunosorbent assay.

RESULTS

Etanercept induced a rapid and sustained clinical improvement of peripheral joint disease. Histologic synovitis was down-regulated, with a profound reduction in global cellular infiltration and T lymphocytes, but not B lymphocytes. The most prominent change in markers of inflammation was a reduction in the different macrophage subsets (CD68, CD163, MRP-8, and MRP-14), but this was not paralleled by a decrease in serum MRP-8/MRP-14. Structural changes included normalization of lining layer hyperplasia and a moderate reduction in vascularity. However, no effect on the microarchitecture of lymphoid aggregates was observed. In terms of an effect on matrix degradation, the synovial expression of MMP-3 and MMP-9 was down-modulated in correlation with a rapid and profound decrease in serum MMP-3. At week 52, serum COMP levels were also reduced. No significant radiologic disease progression was observed in these patients over a 2-year period.

CONCLUSION

Use of etanercept effectively down-modulated the immunopathologic processes of SpA synovitis, both in the short term and in the long term.

Infliximab for juvenile idiopathic arthritis-associated uveitis

BACKGROUND

Infliximab is a murine-human recombinant antitumour necrosis factor monoclonal antibody recently introduced for the treatment of autoimmune diseases in which tumour necrosis factor is thought to be a key mediator. Its role in the treatment of juvenile idiopathic arthritis-associated uveitis is as yet undefined.

METHODS

Six children with juvenile idiopathic arthritis-associated uveitis, inadequately controlled on currently available therapy, were treated with infliximab between September 2002 and November 2004. All children were required to remain on low-dose immunomodulatory treatment in conjunction with the infliximab. A retrospective review of two electronic databases containing details of ophthalmology and rheumatology visits was conducted.

RESULTS

In all six children, institution of infliximab therapy was associated with increased ease of management. Ocular inflammation and intraocular pressure control improved in all. It was also possible to reduce the dose or withdraw some glaucoma, steroid and other immunomodulatory drugs. Two children underwent intraocular surgery without noticeable flare of intraocular inflammation. No patient developed any serious systemic complications attributable to infliximab.

CONCLUSION

Infliximab may be a useful adjunct to the management of refractory juvenile idiopathic arthritis-associated uveitis. In our series it was associated with improved uveitis control and simplification of drug use as well as possibly improving safety of surgical intervention. This study suggests that its role is likely to be in conjunction with maintenance immunomodulatory treatment to provide more optimal disease control. Controlled studies are required to confirm its efficacy and safety, and the potential breadth of its use in uveitis and related disorders.

Actualités sur les modalités thérapeutiques des uvéites

The immunosuppression required for the treatment of uveitis can be achieved through conventional agents or through the use of specific modulators of inflammation. Whatever the choice, it is important to limit side effects: by restricting access to certain drugs in patients presenting a high risk of complications (tuberculosis screening before using Remicade), reducing side effects through preventive measures (use of alendronates during oral corticotherapy), or choosing a local delivery route (intraocular triamcinolone). Intraocular triamcinolone has certain beneficial characteristics such as high local dosage without systemic effect. However, it can cause a pressure rise in 10% to 20% of patients. It requires certain precautions when given to prevent development of a pseudo-endophthalmitis. Remicade is a novel synthetic immunosuppressant directed against TNF-alpha. This chimeric antibody can be useful in the treatment of severe uveitis that is unresponsive to conventional therapy. It is currently being tested in clinical trials in uveitis both in Europe and the USA.

Névrite optique rétrobulbaire associée au traitement par infliximab

Infliximab is a chimeric human-murine monoclonal antibody of the IgG1 type with a high affinity and specificity for tumor necrosis factor alpha (TNFalpha). Infliximab was used in Crohn disease, rheumatoid arthritis, spondyloarthropathy, juvenile idiopathic arthritis, Behcet's disease, Wegener's granulomatosis, HLA-B27-associated uveitis and chronic severe refractory uveitis. Reported adverse effects of this treatment were infections, development of antinuclear antibodies and anti double-stranded DNA, lymphomas, and exacerbation of demyelinating disease. We report a case of infliximab-associated optic neuritis with favorable outcome after systemic steroid treatment.

HLA-B27-associated uveitis: overview and current perspectives

PURPOSE OF REVIEW

To review current knowledge about the pathogenesis, clinical presentation, and treatment of HLA-B27-associated uveitis, which is the most commonly identified cause of uveitis in community-based practice and an important cause of ocular morbidity.

RECENT FINDINGS

Significant advances have been made in understanding the pathogenesis of HLA-B27-associated ocular and systemic disease, especially with regard to the genetic underpinning of these diseases. Increasing attention has also been focused on the use of alternative therapies in the treatment of HLA-B27-associated uveitis, with special attention to sulfa class antibiotics, historically have been used to treat the articular manifestations of the spondyloarthritides, and newer drugs that inhibit tumor necrosis factor-alpha.

SUMMARY

The next several years promise to yield exciting new advances in understanding of the genetic epidemiology and treatment of HLA-B27-associated uveitis.

Crohn's-associated chronic recurrent multifocal osteomyelitis responsive to infliximab

We report a case of chronic recurrent clavicular osteomyelitis in association with Crohn disease. Steroid therapy resulted in partial remission; however, intractable shoulder pain and an enlarging clavicular mass subsequently recurred. Infliximab therapy resulted in significant improvement in the degree of bone pain and resolution of the large sclerotic clavicular lesion.

Infliximab in patients who have spondyloarthropathy: clinical efficacy, safety, and biological immunomodulation

A major breakthrough has been achieved in the treatment of patients who have AS and other types of SpA. The identification of the expression and role of TNF-alpha in patients who have these diseases and the recognition of their relation with gut inflammation (where infliximab therapy has proven efficacious already) has led to the successful use of TNF-alpha blockade in SpA, establishing a new indication for this type of anticytokine therapy. Evidence supports equal response in cases of axial or peripheral disease. Infliximab therapy has been most extensively documented in this new indication for anti-TNF-alpha therapy, but other compounds are also in the field. Gorman et al reported on 40 patients who had active AS who were randomly assigned to receive twice-weekly subcutaneous injections of etanercept (25 mg) or placebo for 4 months [65]. The primary endpoint was a composite of improvements. Treatment with etanercept resulted in significant and sustained improvement (treatment response in 80% in the etanercept group versus 30% in the placebo). Data regarding the human anti-TNF-alpha monoclonal antibody adalimumab in SpA are not yet available. Different questions remain open, including optimal dosing, long-term safety, and effects of this new treatment on the structural articular level; however, a therapeutic breakthrough like the one currently reviewed has seldom occurred in arthritis care.

Biologic therapies in the spondyloarthritis: new opportunities, new challenges

Therapeutic options for patients suffering from the more severe forms of spondyloarthritis have been rather limited in the last decades. There is now accumulating evidence that antitumor necrosis factor therapy is highly effective in spondyloarthritis, especially in ankylosing spondylitis and psoriatic arthritis. Based on the data recently published on more than 500 patients with ankylosing spondylitis and psoriatic arthritis, this treatment seems to be even more effective than in rheumatoid arthritis. The antitumor necrosis factor-alpha agents currently available, infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira), are approved for the treatment of rheumatoid arthritis in the United States and partly in Europe. The situation in spondyloarthritis is different from that of rheumatoid arthritis because there is an unmet medical need, especially in ankylosing spondylitis: no therapies with disease-modifying antirheumatic drugs are available for severely affected patients, especially with spinal disease. Thus, tumor necrosis factor blockers may even be considered a first-line treatment in a patient with active ankylosing spondylitis and psoriatic arthritis whose condition is not sufficiently controlled with nonsteroidal antiinflammatory drugs in the case of axial disease, and sulfasalazine or methotrexate in the case of peripheral arthritis. For infliximab, a dose of 5 mg/kg was required, and intervals between 6 and 12 weeks were necessary to suppress disease activity constantly-also a major aim for long-term treatment. The standard dosage of etanercept is 2 x 25 mg subcutaneously per week. There are no studies yet on adalimumab (standard rheumatoid arthritis dose, 20-40 mg subcutaneously every 1-2 weeks) in spondyloarthritis. Infliximab was very recently approved for AS in Europe. The efficacy of etanercept was first demonstrated in psoriatic arthritis, and it is now approved for this indication. A double-blind study has also been performed in ankylosing spondylitis, with similarly clear efficacy. There is preliminary evidence that both agents do also work in other spondyloarthritis, such as undifferentiated spondyloarthritis. Ideally, both agents will be approved soon for the short-term treatment of severe, uncontrolled spondyloarthritis. In parallel, studies should be performed to document the long-term efficacy of this treatment. There is hope that ankylosis may be preventable, but it remains to be shown whether patients benefit from long-term antitumor necrosis factor therapy and whether radiologic progression and ankylosis can be stopped. Severe adverse events have remained rare. Complicated infections including tuberculosis have been reported. These can be largely prevented by appropriate screening. At it stands now, the benefits of antitumor necrosis factor therapy in ankylosing spondylitis seem to outweigh these shortcomings.

Novel approaches in the treatment of ankylosing spondylitis and other spondyloarthritides

The therapeutic options for patients suffering from severe forms of spondyloarthritis (SpA) have been rather limited in recent decades. There is now accumulating evidence that anti-TNF therapy is highly effective in SpA, especially in ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Based on the data recently published on what is now several hundred AS and PsA patients, this treatment seems to be even more effective than the same therapy in rheumatoid arthritis (RA). The anti-TNF-alpha agents currently available, infliximab (Remicade); Centocor), etanercept (Enbrel); Amgen) and adalimumab (Humira; Abbott), are approved for the treatment of RA in the US; infliximab and etanercept are approved in Europe. The situation in SpA is different to RA because there is an unmet medical need, especially in AS, since no therapies with disease-controlling antirheumatic drugs are available for severely affected patients, especially with spinal disease. Thus, TNF blockers might even be considered as first-line immunosuppressive agents in patients with active AS and PsA who are not sufficiently treated by non-steroidal anti-inflammatory drugs and sulfasalazine, if peripheral arthritis is present. For infliximab, a dosage of 5 mg/kg at intervals between 6 and 12 weeks was necessary to constantly suppress disease activity; this is also a major aim of long-term treatment. No dose-finding studies have yet been performed. The standard dose of etanercept is 25 mg s.c. twice-weekly. No studies on adalimumab (standard RA dose 20 - 40 mg s.c. every 2 weeks) have yet been conducted in SpA. The efficacy of etanercept was first demonstrated in PsA and etanercept is now approved for this indication. A double-blind study has also been performed in AS, with similarly clearcut efficacy. There is preliminary evidence that both agents do also work in other SpA such as undifferentiated SpA. Infliximab has recently been approved for short-term treatment of severe uncontrolled AS; the approval for etanercept is pending. Studies should be performed to document the long-term efficacy of this treatment. There is hope that ankylosis might be preventable but it remains to be shown whether patients benefit from long-term anti-TNF therapy and whether radiological progression and ankylosis can be stopped. Severe adverse events have remained rare. Complicated infections including tuberculosis have been reported. Tuberculosis can be mostly prevented if patients are checked for previous contact with tuberculosis. Currently, the benefits of anti-TNF therapy in AS seem to outweigh these shortcomings.

Anti-tumour necrosis factor agents and tuberculosis risk: mechanisms of action and clinical management

Cases of active tuberculosis have been reported worldwide with the use of therapeutic agents that inhibit tumour necrosis factor (TNF) alpha. TNFalpha has a central role in mycobacterial infection and disease. Accordingly, progression of recently acquired tuberculosis infection or reactivation of remotely acquired infection should be expected with the use of anti-TNF agents. The available in-vitro and epidemiological evidence for the two currently approved agents, infliximab and etanercept, shows that the risk of development of active tuberculosis is greater with infliximab. Tuberculin skin testing (TST) should be undertaken before any significant immunosuppressive therapy including these agents, though the possibility of false-negative reactions in immunocompromised populations must be borne in mind. A positive TST should be followed by medical assessment and chest radiography, as well as by other tests judged appropriate by the physician to identify active disease. Active tuberculosis must be treated appropriately before initiation of treatment with an anti-TNF agent. Treatment of latent tuberculosis can be considered on an individual basis for TST-negative patients receiving anti-TNF agents when significant risk factors for infection are present.

Overview of the use of the anti-TNF agent infliximab in chronic inflammatory diseases

Anti-inflammatory therapy with monoclonal antibodies (mAbs) directed against tumour necrosis factor (TNF)-alpha has emerged as a major advancement in the treatment of various immune mediated diseases such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and Crohn's disease. TNF-alpha seems to play a major pathogenic role in these chronic immune-mediated inflammatory diseases. Infliximab (Remicade), Centocor, Inc., Malvern, PA, USA), a chimaeric mAb, binds to soluble and membrane bound TNF-alpha, but not to TNF-beta. Infliximab is able to effectively regulate and mediate inflammatory processes involved in a number of different disease states. Many clinical trials in these diseases have demonstrated that biological therapy with mAbs directed against TNF-alpha is effective and relatively safe.

Recent progress in ankylosing spondylitis treatment

Ankylosing spondylitis (AS) is a systemic inflammatory rheumatic disease responsible for back pain, stiffness and loss of functional capacity. The therapeutic management of AS includes regular physical exercise together with the use of NSAIDs. Second-line treatments, such as sulfasalazine, are required in cases of NSAID-refractory AS. Some patients have severe and inadequately controlled disease, explaining the need for the development of new treatments. This therapeutic development in AS involves the assessment of new NSAIDs, namely COX2 selective agents and new second-line treatments, such as methotrexate (MTX), pamidronate and anti-TNFalpha agents. Controlled studies are lacking for MTX. Pamidronate showed to be effective in NSAID refractory AS patients in open and controlled trials. Anti-TNFalpha agents (infliximab and etanercept) gave promising results with dramatic improvement of AS symptoms in open and preliminary controlled trials, but further studies are required to evaluate the real long-term effects and tolerability of these drugs.

Mechanisms of bone resorption and new bone formation in spondyloarthropathies

Spondyloarthropathies (SpA) share clinical features such as sacroiliitis, axial immobility, and peripheral arthropathies. They also share a strong association with human leukocyte antigen-B27, implicating T cells and antigen-presenting cells in the disease process. Inflammation seems to underlie the pathogenesis of SpA, particularly in the axial skeleton and entheses. Pathologic bone loss and formation occur simultaneously in inflamed regions, suggesting an inflammation-induced dysregulation of osteoclast and osteoblast activity. Pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNFa) appear to be central to the disease, because TNFa blockade has been shown to effectively improve clinical outcome. Other cytokines such as transforming growth factor-beta, interferon-gamma (IFNg), and interleukin-18 are also likely to be important in SpA. Activated T cells have been shown to produce cytokines such as IFNg and receptor activator of nuclear-factor- kappaB ligand, with direct effects on osteoclastogenesis. The dual role of T cells in immunobiology and skeletal biology provides a possible link between human leukocyte antigen-B27, pro-inflammatory cytokines, and bone cells in SpA.

Gut inflammation and spondyloarthropathies

Spondyloarthropathies (SpA) are a group of related disorders with common clinical and genetic characteristics. The prototype disease in this group is ankylosing spondylitis; other entities include reactive arthritis, psoriatic arthritis, and arthritis in patients with inflammatory bowel disease. Over recent years, there has been a special interest in the relation between spondylitis/synovitis and gut inflammation in patients with SpA. Two thirds of patients with undifferentiated SpA show histologic signs of gut inflammation, and a fraction of these patients go on to develop clinically overt Crohn's disease. In this review, the authors will focus on 1) the growing evidence that has been provided that gut inflammation in SpA is immunologically related to Crohn's disease, based on the molecular characterization of the inflammation (lymphocyte homing markers and ligands, T cell cytokines, macrophage markers, and serology); and 2) on the therapeutic implications resulting from this concept. The recent introduction and positioning of anti-tumor necrosis factor-alpha therapy in patients with ankylosing spondylitis and other types of SpA is, in large part, based on this concept.