Multidisciplinary approach needed for vedolizumab-linked SpA enthesitis/osteitis

The risk of severe spondyloarthritis (SpA)-associated enthesitis/osteitis following successful therapy with vedolizumab for IBD has been highlighted in a small case series.

The study, published in Rheumatology, found de novo SpA in 9 of 11 patients and flare of known SpA in two of the 11 patients who developed severe active SpA and/or enthesopathy on vedolizumab.

Patients were from seven centres across the UK, Italy, Canada and France.

The median time from vedolizumab initiation to flare was 12 weeks, with the IBD well controlled in most patients at flare.

Severe SpA enthesitis/osteitis including acute sacroiliitis, extensive vertebral osteitis, peri-facetal oedema and isolated peripheral enthesitis was evident on MRI or ultrasound.

Four patients required hospitalisation and nine patients discontinued vedolizumab due to the SpA severity.

The findings, that vedolizumab therapy for IBD can be associated with quite severe SpA, suggests a more multidisciplinary approach to patients will be required in the future.

“As we anticipate increasing use of α4β7 inhibition, awareness of this paradoxical reaction and specific phenotype amongst rheumatologists and gastroenterologists alike, can facilitate combined management decisions for effective treatment of IBD and SpA or enthesitis,” the study concluded.

An editorial, co-authored by Professor Matt Brown from the Institute of Health and Biomedical Innovation at the Queensland University of Technology, said vedolizumab (VDZ) had provided ‘new hope for patients who are refractory to TNF inhibitors (TNFis)’ but was not without its downsides.

“In contrast to TNFis, which have been demonstrated to control inflammation both in gut and skeletal manifestations, the presence of concomitant or quiescent SpA is emerging as a challenge for the management of these patients with VDZ, a gut-selective inhibitor,” the editorial said.

“This is a relevant emerging issue for rheumatologists in the practical setting, as risk factors have not yet been identified and the long-term outcome remains unknown.”

While the mechanism is not yet understood, the gut microbiome and gut mucosa barrier function are likely to be involved.

“The reported experience highlights the importance that rheumatologists and gastroenterologists join forces to prospectively study the real effects of VDZ outside the gut.”

“It also highlights the potential risks associated with simplistic repositioning of immunological targeted therapies between diseases. All medications currently in use or in human trials in AS that we are aware of have been repositioned from other indications.”

“In many cases this is despite at least suggestive evidence from immunological or genetic studies that predict non-response or potential contrary treatment effects such as noted here with VDZ.”

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