csDMARDs in axial SpA!

It’s not often you come across exclamation marks in a journal paper, even if it is an editorial. Yet a lively, and interesting, piece by Robert Landewé on the use of conventional synthetic DMARD therapy in patients with axial spondyloarthritis has a record breaking 7 !!!!!!!

It certainly gives an insight into Landewé’s views on the matter, which he says is still under debate despite guidelines being “supposedly clear and unequivocal” that it is not a disease in which csDMARDs including MTX should be prescribed.

According to Landewé some clinicians prefer to manage ‘several shades of grey’ rather than ‘think in black and white’.

“They may argue that absence of evidence (for the efficacy of csDMARDs in axial SpA) does not necessarily mean evidence for the absence of such an effect,” he says in the editorial titled Conventional DMARDs in axial spondyloarthritis: wishful––rather than rational—thinking!

“All too often we tend to build up our body of knowledge by aggregating small pieces of evidence in a seemingly logical manner while ignoring the ‘greater picture’,” he writes.

Eventually, over half way through the editorial and five exclamation marks in, Landewé mentions why he’s writing the editorial in the first place.

Because of results of the ARTIS  study by Lie et al. (read paper here) that he says will “undoubtedly fuel the discussion of whether csDMARD should be co-administered in patients with axial SpA on biological therapy”.

Referring to their analytical approach and their sensitivity analyses as “beautiful” Landewé points to the fact that the researchers say they “only found an association between csDMARD comedication and retention of the first TNFi, not a causal relationship.”

The study is an example of an observational study in which residual confounding seems a far too likely explanation for the association between TNFi-retention and csDMARD co-medication to justify implementation in clinical practice,” concludes Landewé.

To truly test the hypothesis that csDMARDs in axial SpA improve TNFi-retention a well-powered RCT that randomises patients with axial SpA to either monotherapy with a biological or to combination therapy of a biological plus a csDMARD was needed.

Patients would be followed blindly for some time and compare clinical efficacy, safety and drug-retention in both arms.

“Such a trial is feasible, but costly, hard to fund and unfortunately not in the interest of pharmaceutical industries,” he says.

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