TNF Inhibitors Not Very Effective Against Axial Spondyloarthritis in Patients With IBD

Axial spondyloarthritis (axSpA) is one of the common extraintestinal manifestations of inflammatory bowel disease (IBD), observed in up to 13% of patients. Early and effective treatment is critical to limit progression. Anti–tumor necrosis factor (TNF) agents approved for IBD are often used to treat concomitant axSpA and IBD.

Now, Brigham and Women’s Hospital researchers have presented evidence that TNF inhibitors are substantially less effective for axSpA than for IBD within one year.

Rahul S. Dalal, MD, MPH, an attending physician in the Division of Gastroenterology, Hepatology and Endoscopy, Jessica R. Allegretti, MD, MPH, medical director of the Crohn’s and Colitis Center, and colleagues present evidence of the difference in Clinical Rheumatology.


The researchers retrospectively studied 82 adults with IBD and either ankylosing spondylitis or sacroiliitis who initiated an anti-TNF agent approved for IBD (infliximab, adalimumab, golimumab, or certolizumab pegol) between January 1, 2012, and October 1, 2021.

At baseline the median age of the cohort was 41, 39% had prior anti-TNF exposure, 87% had active axSpA symptoms, and 58% had active IBD symptoms. Adalimumab was the most commonly used TNF inhibitor (70% of patients).

Resolution of axSpA Symptoms

The primary outcome was the resolution of axSpA symptoms, defined as “0/10 pain” or “no pain” or “controlled pain,” no appreciable morning stiffness, and no daily requirement for a nonsteroidal anti-inflammatory drug at 12 (±2) months after anti-TNF induction:

  • Entire cohort—52% achieved symptom resolution
  • Anti-TNF naïve—56% achieved symptom resolution

Of 10 patients who had no active axSpA symptoms at baseline, four developed active symptoms within 12 months.

On univariable analysis, IBD duration <5 years (OR, 3.0; 95% CI, 1.2–7.5), and adalimumab use (OR, 2.7 vs. all other anti-TNFs; 95% CI, 1.0–7.1) were associated with significantly higher odds of resolution of axSpA symptoms at 12 months.

IBD Remission

The secondary outcome was clinical remission of IBD, defined as a Simple Clinical Colitis Activity Index <2, Harvey–Bradshaw Index <5 or provider assessment of clinical remission, plus no use of oral or IV steroids during the previous 30 days:

  • Entire cohort—74% achieved clinical remission
  • Anti-TNF naïve—71% achieved clinical remission

Of 61 patients who achieved clinical remission, 32 had data available from colonoscopies performed within 12 months after initiation of anti-TNF therapy. Twenty-three of them achieved endoscopic remission and five achieved endoscopic response.

Opportunities to Improve Care

axSpA does not appear to improve to the same degree as IBD in response to anti-TNF therapy. Patients with IBD and axSpA merit close observation and personalized treatment, including frequent and systematic documentation of axSpA activity and early optimization of therapy to achieve and maintain remission of both diseases.

Close collaboration between gastroenterologists and rheumatologists is also needed to increase the recognition of uncontrolled or undiagnosed axSpA. The Ankylosing Spondylitis Disease Activity Score with CRP (ASDAS-CRP), available as an online calculator, is the most appropriate instrument for monitoring axSpA disease activity.

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