TNF-alpha inhibitors for treating active ankylosing spondylitis and non-radiographic axial spondyloarthritis

Adalimumab, certolizumab pegol, etanercept, golimumab and infliximab are recommended, within their marketing authorisations, as options for treating active ankylosing spondylitis in adults if:

• the condition has a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score of 4 units or more and a spinal visual analogue scale (VAS) of 4 cm or more, and

• non-steroidal anti-inflammatory drugs (NSAIDs) are not suitable have not controlled the conditions well enough.
  
  Infliximab is recommended only if treatment is started with the least expensive infliximab product. People currently having infliximab should be able to continue treatment with the same infliximab product until they and their NHS clinician consider it appropriate to stop.

Adalimumab, certolizumab pegol and etanercept are recommended, within their marketing authorisations, as options for treating non‑radiographic axial spondyloarthritis in adults if:

• the condition has a BASDAI score of 4 units or more and a spinal VAS of 4 cm or more, and

• NSAIDs have not controlled the condition well enough or are not tolerated.

The choice of treatment should be made after discussion between the clinician and the patient about the advantages and disadvantages of the treatments available. This may include considering associated conditions such as extra‑articular manifestations. If more than 1 treatment is suitable, the least expensive (taking into account administration costs and patient access schemes) should be chosen.

The response to adalimumab, certolizumab pegol, etanercept, golimumab or infliximab treatment should be assessed 12 weeks after the start of treatment. Treatment should only be continued if there is clear evidence of response, defined as:

• a reduction in the BASDAI score to 50% of the pre‑treatment value or by 2 or more units and

• a reduction in the spinal pain VAS by 2 cm or more.

Treatment with another tumour necrosis factor (TNF)‑alpha inhibitor is recommended for people who cannot tolerate, or whose disease has not responded to, treatment with the first TNF‑alpha inhibitor, or whose disease has stopped responding after an initial response.

When using BASDAI and spinal pain VAS scores, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the responses to the questionnaires, and make any adjustments they consider appropriate.