Biologic therapy has changed the way AS is managed
What is a biologic?
Unlike medications like paracetamol or ibuprofen, biologic medicines are not manufactured by simply combining specific chemical elements in an ordered process.
Biologic medicines are manufactured within a living system. They are made up of genetically-engineered proteins from living organisms and are very large, complex molecules. Most biologics are designed to block aspects of the immune system.
|Very large and complex medicine||Smaller with a less complex structure|
|Made through a biological process||
Made through a chemical process
|Because they are so large and complex, copies can never be identical.||Exact copies can be made by using the same chemical componnts and processes|
|Copies known as biosimiliars||Copies known as generics|
What biologics are available to treat AS?
There are currently two types of biologic therapy which have been licensed to treat AS and are approved by NICE. We know there are more currently in development and going through clinical trials. Both work by reducing the inflammation produced by the body.
Anti TNF therapy
Anti TNF therapy, is used to treat a range of conditions including non radiographic axial spondyloarthritis and ankylosing spondylitis.
It interferes with the action of a protein called tumour necrosis factor (TNF) which is over-active in the body in people with inflammatory arthritis. This causes inflammation and damage to bones, cartilage and tissue.
Anti TNF therapy blocks the action of TNF and can reduce the amount of inflammation being produced in your body.
Anti TNF medications currently available include:
Anti IL 17A
This type of biologic therapy works by neutralising the activity of a protein in the body called IL 17A.
Research shows that people with AS have very high levels of IL 17A in their body compared with the general population. Researchers discovered that IL 17A plays a very important role in causing the inflammation associated with AS. By neutralising the IL 17A, this biologic reduces inflammation in your body.
The first anti IL 17A secukinumab (Cosentyx®) was approved by NICE and the Scottish Medicines Consortium in 2016.
In February 2016, NICE published updated guidance for the use of anti TNF therapy
Known as TA383, these guidelines make a number of recommendations.
- All the available anti TNF therapies are recommended as options for treating AS
This means you and your rheumatologist can choose any of the anti TNF therapies on the market, including infliximab (cheapest version). Previously infliximab was not available to people with AS on the grounds of cost. NICE recommend the choice of treatment should be made after discussion between the rheumatologist and the patient about the advantages and disadvantages of the treatments available.
- Adalimumab (Humira), certolizumab pegol (Cimzia) and etanercept (Enbrel) are recommended, as options for treating severe non-radiographic axial spondyloarthritis
This means that anti TNF therapy can now be used earlier. The previous guidance specified that people needed a diagnosis of AS, where changes to the sacroilliac joints and /or the spine could be seen on x-ray. This left some people living in pain as they had all the symptoms of AS, but they did not have changes on x-ray. Now the guidance includes people with non-radiographic axial spondyloarthritis which is where no changes are yet visible on x-ray. If you have previously been told that your x-ray or MRI results don't meet the criteria for you to go onto anti TNF therapy, it may be time to ask again.
- Treatment with another anti TNF is recommended for people who cannot tolerate, or whose disease has not responded to, treatment with the first TNF-alpha inhibitor, or whose disease has stopped responding after an initial response
Until now, NICE guidance only allowed people to try one anti TNF, unless they had side effects in the first 12 weeks. If the first anti TNF didn't work or if effectiveness wore off over time, NICE did not recommend trying another anti TNF.
Now your rheumatologist can think about trying you on another anti TNF if your first anti TNF didn't work or if the effect has worn off over time.
Taking anti TNF therapy
You may find this video from Torbay and South Devon Rheumatology department useful.
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