Ankylosing Spondylitis with Recurrent Anterior Uveitis or Active Inflammatory Bowel Disease: Treatment After TNF Monoclonal Antibody Failure
This protocol addresses the next treatment step for patients with ankylosing spondylitis who have recurrent anterior uveitis or active inflammatory bowel disease and whose initial TNF monoclonal antibody therapy did not achieve the required disease-control targets.
Clinical Scenario
When ankylosing spondylitis is accompanied by recurrent anterior uveitis or active inflammatory bowel disease (IBD), initial biologic selection reflects the need to manage these extra-articular features alongside axial inflammation. Preference in this setting is given to monoclonal antibodies directed against TNF.
Active IBD also imposes a key therapeutic constraint: certain biologic classes are contraindicated, which directly shapes the options available at the next treatment line.
When the Previous Treatment Did Not Work
This protocol applies after a TNF monoclonal antibody — infliximab, adalimumab, certolizumab pegol, or golimumab — has failed to achieve either of the following:
- A clinically important improvement in ASDAS (decrease ≥1.1) after at least 12 weeks of treatment
- Prevention of uveitis recurrence
Next-Line Approach
After failure of the initial TNF monoclonal antibody, switching to a different biologic or targeted agent is indicated. The full protocol specifies which classes are applicable in the context of active uveitis or IBD, and how the IBD-related contraindication is factored into the selection.
Treatment target: ASDAS clinically important improvement (decrease ≥1.1), assessed after at least 12 weeks of the new regimen.
References
DOI: 10.1136/ard-2022-223296
If there is a history of recurrent uveitis or active IBD, preference should be given to a monoclonal antibody against TNF.
In patients with active IBD, IL-17i are contraindicated.
Following a first b/tsDMARD failure, switching to another bDMARD (TNFi or IL-17i) or a JAKi should be considered.
Figure 3 summarises the criteria for continuation, namely that after at least 12 weeks of treatment, the disease activity has substantially decreased, as assessed by the ASDAS clinical important improvement, that is, improvement in ASDAS ≥1.1, together with the positive opinion from the rheumatologist to continue.
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