Whether spondyloarthritis (SpA) is one disease or many is still up for debate but both sides are closer than they realise.
Speaking at the 5th World Congress on Controversies, Debates & Consensus in Bone, Muscle & Joint Diseases, Professor Maxime Dougados said SpA was one disease with multiple clinical presentations.
“Start with SpA and then add in adjectives,” he quipped.
Former EULAR president Professor Dougados, from the Paris Descartes University in France, said the fact that clinical features aggregated in families was strong evidence that SpA was a single entity.
He said diagnosis, monitoring and treatment were also facilitated by accepting that SpA was one disease.
“Even if a patient is presenting with only one symptom, we should always be asking about the others.”
However Dr Peter Nash, director of the University of Queensland’s Rheumatology Research Unit on the Sunshine Coast, said it was better for patients if SpA was multiple distinct entities.
“Patient identify with labels and may be confused by SpA,” he said.
But more importantly, and practically, treatment was based on specific indications.
“The regulators don’t get the SpA concept; dermatologists and gastroenterologists don’t get the SpA concept. They can be educated but it’s very difficult,” he said.
“What we really want is access to reimbursed therapies and they are all put in little boxes. I can get ustekinumab for psoriatic arthritis but not for ankylosing spondylitis. I can get apremilast for psoriasis but not for this, that, and the other.”
“At the end of the day, no matter how they all interrelated, it’s treating the patients that’s important and very dependent on what reimbursers let us do.
Associate Professor Nash said that conditions such as Behcet’s syndrome and Whipple’s disease had already been split off and those patients had a better chance of being cured.
“Whipple’s disease can be cured. If it was labelled as SpA, it might not have.”
He said a more modern approach would come with time and more rheumatology input into the TGA and PBAC.
“We’ve already seen it. When we first got reimbursed therapy for rheumatoid arthritis, you had to be seropositive. Now you can be seronegative or seropositive.”
Professor Dougados added it was impossible to run clinical research into SpA without collecting information on all the different phenotypes.