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Keywords:

  • ankylosing spondylitis;
  • disease activity;
  • therapy

Abstract

Aim

The effect of disease-modifying antirheumatic drugs (DMARDs) in ankylosing spondylitis (AS) is still controversial. We aimed to evaluate the efficacy of sulphasalazine (SSZ) mono- or combination therapy with methotrexate (MTX) in AS patients naive to anti-tumor necrosis factor alpha (TNFα) agents.

Methods

Patients with AS (= 87, male : female, 46 : 41) treated with SSZ (= 61) or SSZ + MTX (= 26) combination and a documented 6-month follow-up were evaluated retrospectively. Disease activity was assessed by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), C-reactive protein and erythrocyte sedimentation rate. Requirement for anti-TNFα therapy was assessed after 6 months.

Results

Mean (SD) age was 43.0 (11.0) versus 40.2 (11.1) and disease duration was 11.0 (8.6) versus 8.2 (5.2) years, in the SSZ and SSZ + MTX groups, respectively. Initially, 59% (34/61) of the patients in SSZ monotherapy and 68% (17/26) in the combination arm had BASDAI > 4. At the end of the study, BASDAI scores decreased similarly in both groups (mono: 1.4 [–7–6] versus combination: 0.7 [–3–6] = 0.2). BASDAI was > 4 in 32.8% (20/61) of patients in the SSZ monotherapy and in 44% (11/26) in the combination arm. Only 4 (6.6%) patients in the SSZ group and 2 (7.7%) in the ombination arm were switched to anti-TNFα therapies.

Discussion

A significant subset of our AS patients responded to SSZ mono or SSZ + MTX combination therapies at 6 months follow-up. Using BASDAI, the requirement for biological therapies decreased by 21–24%. In AS patients, including those with axial involvement only, DMARD therapy may be a reasonable first alternative to anti-TNFα therapy and may delay the switch to biologic agents.