Editorial review: how early should ankylosing spondylitis be treated with a tumor necrosis factor-blocker?

Therapy of ankylosing spondylitis with tumor necrosis factor (TNF)-blockers is very effective in about 50% of patients. The focus of this review is to discuss how early in the course of the disease patients with axial spondyloarthritis should be treated with TNF-blockers.

During the last 10 years TNF-blockers were investigated in established ankylosing spondylitis. More recently clinical trials focused on early treatment including patients with axial nonradiographic spondyloarthritis. It could be shown that TNF-blockers are at least as effective in patients with axial nonradiographic spondyloarthritis when compared with established ankylosing spondylitis and that TNF-blockers are even more effective when used earlier in the course of the disease and in younger age. Some data even indicate that drug-free remission might be achieved if patients are treated earlier. Active inflammation as seen by MRI can effectively be suppressed during therapy with TNF-blockers. It has been hypothesized that early anti-inflammatory treatment is the best way to prevent ankylosis, which has to be proven in future studies.

TNF-blockers can achieve a higher clinical response if ankylosing spondylitis patients and patients with nonradiographic axial spondyloarthritis are treated earlier. Whether very early treatment affects ankylosis has to be further investigated.