Achieving drug-free remission in axial spondyloarthritis: Exploring the role of tight control in early disease

Early therapeutic interventions in inflammatory rheumatic diseases have proven successful in inducing drug-free remission, and EULAR—The European Alliance of Associations for Rheumatology—recommends early intervention in arthritis, since conventional synthetic disease-modifying antirheumatic drugs (csDMARD) have been shown to slow disease progression in both rheumatoid and psoriatic arthritis.

Even though early therapeutic interventions have proven successful in inducing drug-free remission in other inflammatory rheumatic diseases, such studies remain difficult to conduct in axial spondyloarthritis (axSpA), which manifests itself by insidious onset inflammatory back pain. As a result, it is often diagnosed late, and a consensus definition of early disease was only recently published.

At the 2024 EULAR congress, Łukasik and colleagues shared data from their prospective study evaluating the efficacy of a tight control, treat-to-target approach in newly diagnosed, treatment-naïve axSpA patients, following the ASAS-EULAR disease management recommendations.

Patients were treated with two different non-steroidal anti-inflammatory drugs (NSAID) at optimal doses for a period of at least 4 weeks, but if they did not achieve clinically important improvement, then monotherapy with golimumab was started. Patients were followed until achieving sustained clinical remission—defined as ASDAS-CRP inactive disease state at two consecutive visits with at least 12 weeks interval—or the end of trial. After achieving sustained clinical remission, treatment was stopped and participants were followed in routine clinical practice to evaluate the possibility of maintaining drug-free remission.

Of 55 patients who completed the trial, 61.8% achieved sustained clinical remission, and 21.8% had low disease activity at week 52. This is the first clinical trial in early axSpA in which sustained inactive disease status has been achieved in over 60% of patients. In univariate analysis, only sex and baseline BASDAI scores were significantly different between those who did and did not achieve sustained clinical remission. Further multivariate analysis revealed that male sex, abstinence from smoking, and lower BASDAI score were predictors of remission.

Of those who achieved sustained clinical remission and were taken off treatment, 84.8% experienced a disease relapse within 1 year. This happened for all patients who achieved their remission state with NSAID treatment, and the median time to relapse was 61 days—whereas in the golimumab group it was 155 days and 18.2% of patients remained in drug-free remission for over 3 years of follow-up.

Thus, a treat-to-target approach is able to induce high rates of inactive disease in early axSpA. However, inducing drug-free remission in axSpA remains challenging.