Treatment strategies for Spondyloarthritis: Implementation of precision medicine - Or "one size fits all" concept?

Spondyloarthritis (SpA) is a term to describe a group of chronic inflammatory rheumatic diseases, which have common pathophysiological, genetic, and clinical features. Under the umbrella term SpA, two main groups are subsumed: axial SpA (radiographic axSpA and non-radiographic axSpA) and peripheral SpA (with the leading representative being psoriatic arthritis (PsA) but also arthritis associated with inflammatory bowel disease (IBD), reactive arthritis, and undifferentiated pSpA). The key clinical symptom in axSpA is chronic back pain, typically with inflammatory characteristics, which starts in early adulthood, while the leading clinical manifestations of peripheral SpA (pSpA) are arthritis, enthesitis, and/or dactylitis. Furthermore, extra-musculoskeletal manifestations (EMMs) (acute anterior uveitis, psoriasis, and IBD) can accompany axial or peripheral symptoms. All these factors need to be taken into account when making treatment decisions in SpA patients. Despite the major advances in the treatment landscape over the past two decades with the introduction of biological disease-modifying anti-rheumatic drugs (bDMARDs) and most recently targeted synthetic DMARDs (tsDMARDs), a relevant proportion of patients still does not achieve the desired state of remission (=absence of disease activity). With this implementation of new treatment modalities, clinicians now have more choices to make in the treatment algorithms. However, despite generalized treatment recommendations, all factors need to be carefully considered when deciding on the optimal treatment strategy for an individual patient in clinical practice, aiming at an important first step towards personalized treatment strategies in SpA. In this narrative review, we focus on the efficacy of approved and emerging treatment options in axSpA and PsA as the main representative of pSpA and discuss their selective effect on the different manifestations associated with SpA to provide guidance on drivers of treatment decisions in specific situations.
Competing Interests: Declaration of competing interest TID: has nothing to disclose. FP: received grants and personal fees from Novartis, Eli Lilly, and UCB and personal fees from AbbVie, AMGEN, BMS, Celgene, Galapagos, Janssen, Hexal, Medscape, MSD, Pfizer and Roche outside the presented work. KG: received grants or contracts from Bristol Myers Squibb; received consulting fees from Abbvie, Lilly, Almirall, Janssen, Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, and UCB; received payment /honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from Abbvie Allergan Alimera Bayer Novartis Pfizer Roche Santen Thea; received support for attending meetings and/or travel from Abbvie, Almirall, BMS, and Lilly. UP: received grants or contracts from EU, BMBF; received consulting fees from Affibody, Alcon, Allergan, Janssen, Novartis, Panoptes, Pfizer, Roche, Thea, Lilly, Pfizer, Santen. Holds patents EP 19732357.9, PCT/EP2019/066419, PCT/J/2020–570,837.BS: received grants or contracts from Pfizer; received consulting fees from Abbvie, Abivax, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Endpoint Health, Falk Pharma, Galapagos, Gilead, Janssen, Landos, Lilly, Pfizer, and Takeda; received payment /honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from Abbvie, BMS, CED Service GmbH, Eli Lilly, Falk Pharma, Ferring, Galapagos, Janssen, Lilly, Pfizer, and Takeda.DP: received consulting fees from AbbVie, Biocad, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, MSD, Moonlake, Novartis, Pfizer, Samsung Bioepis and UCB; received payment /honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, MSD, Medscape, Novartis, Peervoice, Pfizer and UCB.
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