Review Question - QID 5417

The male patient has ankylosing spondylitis (AS), and is taking the same medication as his wife, who has rheumatoid arthritis (RA). Adalimumab is approved for both conditions.

TNF-a inhibitors are biological agents approved for 2nd-line treatment of AS. These include etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol, which are all approved for treatment of RA and psoriatic arthritis as well. Additional biological agents unique to RA are IL1 antagonists (e.g. anakinra), B cell inhibitors (rituximab), T cell inhibitors (abatacept), IL6 receptor inhibitors (tocilizumab) and Janus kinase (JAK) pathway inhibitors (tofacitinib).

Kubiak et al. reviewed the orthopaedic management of AS. They support using anti–TNFa medications when there is: (1) definitive diagnosis of AS, (2) disease lasting > 4 weeks, (3) refractory disease, (4) failure of corticosteroid sacroiliac joint injections, (5) failure of sulfasalazine for peripheral disease, and (6) no medical contraindications to the initiation of treatment.

Khalessi et al. reviewed the medical management of AS. They discuss physical therapy, education, and medications and radiation therapy. Non-biological medications include NSAIDs, coxibs, corticosteroids and DMARDS (sulfasalazine and methotrexate). They note that both sulfasalazine and methotrexate do not improve pain or function from AS spinal disease.

Figure A shows bilateral sacroiliitis and bilateral hip arthritis, which in a young male patient, is highly suggestive of AS. Figure B shows ulnar drift of the digits and MCPJ subluxation characteristic of RA.

Incorrect Answers:
Answer 1: Denosumab is a RANKL inhibitor, mimicking the action of osteoprotegerin. As Prolia, it is used to treat osteoporosis. As Xgeva, it is used for prevention of skeleton-related events in patients with bone metastases, giant cell tumors, multiple myeloma with bone metastases, and hypercalcemia of malignancy.
Answer 3: Tofacitinib is an oral Janus kinase (JAK) pathways inhibitor and is second-line treatment for moderate to severe RA.
Answer 4: Imatinib is a tyrosine-kinase inhibitor used to treat Philadelphia chromosome-positive (Ph+) chronic myelogenous leukemia (CML).
Answer 5: Rituximab is a CD20+ B cell inhibitor and is used to treat moderately to severe RA unresponsive to therapy with 1 or more TNF antagonists.