[Difficult-to-treat rheumatoid arthritis]. / Polyarthrite rhumatoïde difficile à traiter.

Rheumatoid arthritis is the most common inflammatory arthritis and has benefited from significant advances in its management in the past years. However, specific challenges persist, including the management of difficult-to-treat rheumatoid (D2TRA), which is defined by the failure of at least two biological or targeted synthetic disease-modifying antirheumatic drugs with a different mechanism of action. D2TRA reported prevalence is from 5 to 20 %. EULAR (European Alliance of Associations for Rheumatology) proposed a step-by-step approach for managing D2TRA, starting with confirmation of diagnosis, assessment of inflammatory activity, immunosuppressive treatment choice and non-pharmacological treatment.

La prise en charge de la polyarthrite rhumatoïde (PR), rhumatisme inflammatoire le plus fréquent dans la population, a bénéficié d'importantes avancées ces dernières années. Mais certains défis persistent pour le rhumatologue, comme la prise en charge de la PR difficile à traiter. Cette dernière est définie notamment par l'échec de deux immunosuppresseurs à mécanismes d'action différents. Sa prévalence est de 5 à 20 %. L'approche par étapes proposée par l'European alliance of associations for rheumatology (EULAR) comprend la vérification du diagnostic, l'évaluation objective de l'activité inflammatoire et l'optimisation du traitement immunosuppresseur associée à la prise en charge non médicamenteuse.

Real-life drug retention rate and safety of rituximab when treating rheumatic diseases: a single-centre Swiss retrospective cohort study.

BACKGROUND: In Switzerland, rituximab (RTX) is licenced for the treatment of rheumatoid arthritis (RA) and ANCA-associated vasculitis (AAV) but is frequently used off-label to treat other auto-immune diseases (AID), especially connective tissue diseases (CTD). We aimed to characterise the use of RTX in AID in a real-life Swiss setting and compare RTX retention rates and safety outcomes between patients treated for RA, CTD and AAV. METHODS: A retrospective cohort study of patients who started RTX in the Rheumatology Department for RA or AID. The RTX retention rate was analysed using Kaplan-Meier survival curves. Occurrences of serious adverse events (SAE), low IgG levels and anti-drug antibodies (ADA) were reported. RESULTS: Two hundred three patients were treated with RTX: 51.7% had RA, 29.6% CTD, 9.9% vasculitis and 8.9% other AIDs. The total observation time was 665 patient-years. RTX retention probability at 2 years (95%CI) was similar for RA and CTD 0.65 (0.55 to 0.73), 0.60 (0.47 to 0.72) and lower for vasculitis 0.25 (0.09 to 0.45). Survival curves for RTX retention matched closely (p = 0.97) between RA and CTD patients but were lower for patients with vasculitis due to a higher percentage of induced remission. Patients with vasculitis (95%) and CTD (75%) had a higher rate of concomitant glucocorticoid use than RA (60%). Moderate to severe hypogammaglobulinaemia was observed more frequently in patients with vasculitis (35%) than with RA (13%) or CTD (9%) and was associated with an increased risk of presenting a first infectious SAE (HR 2.01, 95% CI 1.04 to 3.91). The incidence rate of SAE was 23.3 SAE/100 patient-years (36% were infectious). When searched, ADAs were observed in 18% of the patients and were detected in 63% of infusions-related SAE. 10 patients died during RTX treatment and up to 12 months after the last RTX infusion, 50% from infection. CONCLUSION: RTX retention rates are similar for patients with RA and CTD but lower for those with vasculitis due to more frequent remission. Patients treated with RTX for vasculitis present more SAE and infectious SAE than patients with RA and CTD, potentially due to a higher use of concomitant glucocorticoids and the occurrence of hypogammaglobulinaemia.

[Janus kinase inhibitors : new perspectives for precision medicine ?] / Inhibiteurs des Janus kinases : nouvelles perspectives pour la médecine de précision ?

Janus kinase inhibitors (JAKi), such as tofacitinib, baricitinib, upadacitinib or ruxolitinib, are small molecules active on specific intracellular targets and used orally for the treatment of autoimmune or myeloproliferative diseases. Their remarkable therapeutic efficacy is offset by a significant risk of toxicities, essentially dose-dependent and a variable pharmacokinetic profile. The JAKi represent a new therapeutic armamentarium for treating autoimmune, myeloproliferative and inflammatory diseases (incl. COVID-19), but require thorough treatment individualization and close monitoring. Therapeutic Drug Monitoring (TDM) of JAKi could allow a personalized prescription and improve the efficacy-toxicity profile.

Les inhibiteurs des Janus kinases (JAKi), tels que le tofacitinib, le baricitinib, l'upadacitinib ou le ruxolitinib, représentent une nouvelle classe de petites molécules actives sur des cibles intra-cellulaires spécifiques, utilisables par voie orale pour traiter des maladies autoimmunes ou néoplasies myéloprolifératives. Leur efficacité thérapeutique remarquable est contrebalancée par un risque significatif de toxicités essentiellement dose-dépendantes et un profil pharmacocinétique variable. Les JAKi constituent une nouvelle arme thérapeutique pour le traitement des maladies autoimmunes, myéloprolifératives et inflammatoires (Covid-19), mais nécessitent une individualisation et un suivi attentifs. Le suivi thérapeutique des médicaments des JAKi pourrait permettre de personnaliser leur prescription et améliorer leur profil efficacité-toxicité.

Idiopathic remitting seronegative symmetrical synovitis with pitting edema syndrome mimicking symptoms of polymyalgia rheumatica: a case report.

BACKGROUND: Remitting seronegative symmetrical synovitis with pitting edema is a rare rheumatic condition of the elderly population that is well described but whose mechanisms remain little studied. This syndrome is characterized by symmetrical swelling located mainly on the dorsal part of the hands and the feet. Because of possible heterogeneous clinical presentation, it can easily mimic the onset of other rheumatic diseases or appear associated with them. Here we report a case of a patient who developed remitting seronegative symmetrical synovitis with pitting edema with preexisting shoulder and hip girdle pain associated with progressive fatigue, indicating a possible differential diagnosis of polymyalgia rheumatica. We reviewed and compared classification for remitting seronegative symmetrical synovitis with pitting edema and polymyalgia rheumatica and discussed other differential diagnoses. CASE PRESENTATION: An 84-year-old Caucasian woman presented to our General Medicine Unit with acute onset of symmetrical hands and feet edema, leading to functional limitation due to pain and stiffness. Additionally, she was complaining about neck, shoulder, and pelvic girdle pain present for about 2 months associated with worsening asthenia. Blood tests showed an elevated level of C-reactive protein and erythrocyte sedimentation rate, as well as absence of anti-cyclic citrullinated peptide antibodies and rheumatoid factor. As all criteria of remitting seronegative symmetrical synovitis with pitting edema syndrome were present, the patient was treated with low-dose prednisone, with a rapid and complete resolution of symptoms. She remains asymptomatic without treatment 2 years after the onset of symptoms, without any evident oncologic etiology. CONCLUSIONS: This case is an example of a classic representation of remitting seronegative symmetrical synovitis with pitting edema syndrome with clinical elements suggesting a concomitant existing early stage of polymyalgia rheumatica. These two entities, classified in the group of seronegative arthritis, can coexist (up to 10% of cases), with remitting seronegative symmetrical synovitis with pitting edema appearing as an initial or late manifestation of polymyalgia rheumatica. It is essential to remind that remitting seronegative symmetrical synovitis with pitting edema is associated with a higher risk of cancer (30%). A proper diagnosis allows the clinician to precisely define the appropriate therapy duration to limit its side effects in the elderly and remain aware of the potential risk of underlying malignancy.

Dorsal Finger Fold Recognition by Convolutional Neural Networks for the Detection and Monitoring of Joint Swelling in Patients with Rheumatoid Arthritis.

Digital biomarkers such as wearables are of increasing interest in monitoring rheumatic diseases, but they usually lack disease specificity. In this study, we apply convolutional neural networks (CNN) to real-world hand photographs in order to automatically detect, extract, and analyse dorsal finger fold lines as a correlate of proximal interphalangeal (PIP) joint swelling in patients with rheumatoid arthritis (RA). Hand photographs of RA patients were taken by a smartphone camera in a standardized manner. Overall, 190 PIP joints were categorized as either swollen or not swollen based on clinical judgement and ultrasound. Images were automatically preprocessed by cropping PIP joints and extracting dorsal finger folds. Subsequently, metrical analysis of dorsal finger folds was performed, and a CNN was trained to classify the dorsal finger lines into swollen versus non-swollen joints. Representative horizontal finger folds were also quantified in a subset of patients before and after resolution of PIP swelling and in patients with disease flares. In swollen joints, the number of automatically extracted deep skinfold imprints was significantly reduced compared to non-swollen joints (1.3, SD 0.8 vs. 3.3, SD 0.49, p < 0.01). The joint diameter/deep skinfold length ratio was significantly higher in swollen (4.1, SD 1.4) versus non-swollen joints (2.1, SD 0.6, p < 0.01). The CNN model successfully differentiated swollen from non-swollen joints based on finger fold patterns with a validation accuracy of 0.84, a sensitivity of 88%, and a specificity of 75%. A heatmap of the original images obtained by an extraction algorithm confirmed finger folds as the region of interest for correct classification. After significant response to disease-modifying antirheumatic drug ± corticosteroid therapy, longitudinal metrical analysis of eight representative deep finger folds showed a decrease in the mean diameter/finger fold length (finger fold index, FFI) from 3.03 (SD 0.68) to 2.08 (SD 0.57). Conversely, the FFI increased in patients with disease flares. In conclusion, automated preprocessing and the application of CNN algorithms in combination with longitudinal metrical analysis of dorsal finger fold patterns extracted from real-world hand photos might serve as a digital biomarker in RA.

[Use of clinical scores for rheumatoid arthritis and inflammatory rheumatic diseases in routine care]. / Utilité des scores pour le suivi de la polyarthrite rhumatoïde et autres arthropathies inflammatoires.

Many clinical scores have been developed in research to measure rheumatoid arthritis (RA), spondyloarthritis (SpA) and psoriatic arthritis (PsA) activity. In routine care, they may be used as part of a treat to target (T2T) strategy consisting of a systematic evaluation of disease activity followed by an adaptation of the treatment in order to reach a predefined therapeutic target, generally remission. The benefits of this strategy have been showed in RA and its use is recommended for this condition. The added value of the T2T strategy for SpA and PsA remains debated, requiring further studies. Scores may be used for the follow-up of patients, but their limitations should be taken in consideration.

De nombreux scores cliniques ont été développés en recherche pour mesurer l'activité de la polyarthrite rhumatoïde (PR), de la spondylarthrite (SpA) et de l'arthrite psoriasique (PsA). Ils peuvent être utilisés en pratique dans l'application de la stratégie « Treat to Target ¼ (T2T) consistant en une évaluation systé matique de l'activité de la maladie suivie d'une adaptation du traitement afin d'atteindre un objectif thérapeutique prédéfini, généralement la rémission. Les bénéfices de cette stratégie étant démontrés dans la PR, son utilisation est recommandée pour cette pathologie. L'apport de la stratégie T2T pour la SpA et la PsA reste débattu, nécessitant des études complémentaires. L'utilisation d'un score dans le suivi individuel d'un patient peut être utile mais doit se faire avec discernement en connaissance des limites du score.

[Sexism and gender inequalities in hospitals of Western Switzerland: junior doctors perspectives]. / Harcèlement, sexisme et inégalité de genre dans les hôpitaux romands - Le point de vue des médecins en formation.

Sexism and gender inequalities are well-known issues in medical community and hospitals are also concerned. The Swiss Junior Doctors Association, local branch (canton of Vaud) conducted a survey about this topic. 44% of participants (67-186 junior doctors answered the survey) have been victims or witnessed sexist remarks. 76% heard hostiles speeches about pregnancy. 62% of pregnant women did not benefit from measures provided by Swiss law. 82 % of mothers experienced pregnancy as a career-limiting event. Human resources and management have responsibility for reporting discriminatory behavior and taking appropriate actions. Having children should be valued and pregnant women protected according to Swiss law, which should be enforced without conditions.

La question du sexisme et de l'inégalité de genre est connue en milieu médical et les hôpitaux romands ne sont pas épargnés. L'Association suisse des médecins assistant·e·s et chef·fe·s de clinique, Section Vaud, a soumis à ses membres un sondage sur ce thème. 44 % des répondant·e·s (67 à 186 participant·e·s selon les questions) ont été victimes/témoins de remarques sexistes. 76 % ont entendu des discours hostiles à la grossesse. 62 % des femmes enceintes n'ont pas bénéficié des mesures prévues par la Loi sur le Travail (LTr). 82 % des mères vivent la maternité comme un frein à la carrière. Les ressources humaines et directions ont la responsabilité d'encourager la dénonciation des comportements problématiques et de prendre des mesures. Le projet familial doit être valorisé et la protection de la grossesse, réglée par la LTr, appliquée sans condition.

[Sjögren's syndrome: from diagnosis to treatment]. / Syndrome de Sjögren : du diagnostic au traitement.

Sjögren's syndrome (SS) is an auto-immune condition involving salivary and lacrymal glands leading to dry mouth and dry eyes symptoms. Some patients also present with systemic manifestations. Diagnosis of SS is made after clinical, serological, and histological assessment according to the American College of Rheumatology and European League Against Rheumatism (EULAR) classification criteria. Recent clinical trials showed a significant decrease of systemic activity of SS in patients treated with iscalimab (anti-CD40) and ianalumab (anti-BAFF-R). These results need to be confirmed in larger studies. However, two phase 3 randomized trials did not show efficacy treating SS with abatacept. We also describe in this article the first EULAR recommendations on SS management.

Le syndrome de Sjögren (SS) est une pathologie autoimmune se présentant habituellement par une sécheresse oculo-buccale ou par des manifestations systémiques de présentation variable. Le diagnostic se base sur des éléments cliniques, biologiques et histologiques selon les critères définis par l'American College of Rheumatology et l'European League Against Rheumatism (EULAR). Sur le plan thérapeutique, des études cliniques récentes ont montré l'efficacité de nouvelles molécules comme l'iscalimab (anti-CD40) ou l'ianalumab (anti-BAFF-R) sur l'atteinte systémique du SS, qui devra être confirmée dans de plus grandes études. Deux études de phase 3 n'ont en revanche pas pu démontrer l'efficacité de l'abatacept. L'EULAR a publié les premières recommandations européennes de prise en charge du SS que nous décrivons dans cet article.

[Rheumatology and COVID-19]. / Rhumatologie et COVID-19.

Current pandemic implies changes in patient care in rheumatology to reduce the risk of coronavirus transmission to patients visiting health-care facilities, by organizing less frequent blood tests, using teleconsultations, and switching from intravenous to subcutaneous drug administration. Patients under immunosuppressive treatment are considered at high risk of severe outcome and are protected accordingly by the Swiss authorities. However, current, scarce scientific evidence suggests that patients under immunosuppressive therapy do not necessarily develop severe COVID-19 presentations. Therefore, the current guidelines recommend pursuing the treatment throughout the pandemic. In case of SARS-CoV-2 infection, immunosuppressive drugs should be temporarily stopped, except for glucocorticoids, hydroxychloroquine and sulfasalazine.

La pandémie a impliqué une réorganisation des soins en rhumatologie pour limiter les déplacements des patients : espacement des prises de sang, administration sous-cutanée des traitements, téléconsultations. Les patients traités par immunosuppresseurs sont reconnus comme vulnérables par les autorités et bénéficient des protections qui en découlent. Sous réserves du peu de données disponibles, il n'est pas constaté d'augmentation du risque de développer de formes graves de COVID-19 chez les patients souffrant de rhumatismes inflammatoires traités par immunosuppresseurs. Il existe ainsi un consensus pour recommander la poursuite de ces traitements pendant la pandémie. Leur arrêt n'est recommandé qu'en cas d'infection avérée à SARS-CoV-2, à l'exception de la prednisone, de l'hydroxychloroquine et de la sulfasalazine qui peuvent être poursuivis.

[Arthritis 4.0†: The digital cycle has begun]. / Arthrite 4.0†: le cycle numérique est en marche.

Current digital solutions in rheumatology support patients in terms of information and communication. E-diagnosis and symptom checker potentially reduce the delay of diagnosis. Patient reported outcome is increasingly used to monitor disease activity. In future, motion tracker and other types of sensors e.g. in smartphones might provide further information in order to predict disease flares. Artificial intelligence will likely be used for disease stratification, prediction and treatment choice. Together a «â€…digital cycle ¼ including diagnosis, surveillance and treat-ment decision is going to be established. The role of the rheuma-tologists within this cycle needs to be defined.

En rhumatologie, les applications numériques visent actuellement avant tout à informer et à mieux communiquer avec les patients. A l'avenir, les aides électroniques au diagnostic aideront à établir plus rapidement des diagnostics rhumatologiques pour un traitement encore plus précoce. Aujourd'hui déjà, les patients atteints de polyarthrite rhumatoïde (PR) enregistrent l'activité de leur maladie sur leur smartphone. Ces données collectées par les smartphones, les dispositifs portables ou par l'intermédiaire de capteurs de diverses formes fournissent au moins indirectement des informations sur l'activité de la maladie et servent ainsi de biomarqueurs numériques. C'est cependant l'intelligence artificielle qui constitue le plus grand défi. Celle-ci nous permettra probablement de mieux comprendre et traiter les maladies rhumatologiques à l'avenir.

Efficacy of anakinra in acute hydroxyapatite calcification-induced joint pain: A retrospective study of 23 cases.

OBJECTIVE: Hydroxyapatite (HA) crystal calcifications in or around the joint can induce acute flares with severe pain. A previous pilot study suggested that the interleukin-1ß (IL-1ß) inhibitor anakinra was effective. The goal of this observational study was to confirm these results in a larger set of patients and to report on the long-term follow-up. METHODS: Flare was defined as acute pain for<10 days. Calcification in or around a joint (rotator cuff: 15/23 patients) was confirmed by conventional radiography and/or ultrasonography (US). Anakinra 100mg daily was administered subcutaneously for 1 to 3 consecutive days. Clinical data collected before the injection and on days 3 and 21 included pain score on a visual analog scale (VAS, 0-10cm) and C-reactive protein (CRP) level. When available, US baseline and follow-up findings were compared. Long-term follow-up data were collected from patient charts and/or after a phone call. RESULTS: 23 patients (15 males, mean [SD] age 58 [11] years) were included. Baseline mean (SD) VAS pain was 7.7 (1) cm and CRP level was elevated in half of the patients. After therapy, mean (SD) VAS pain score decreased rapidly in the first 3 days to 1.6 (1.4) cm (P<0.001) and remained stable for 3 weeks at 1.8 (2.1) cm. US assessment revealed decreased Doppler intensity but no significant change in size of calcifications. No significant side effects were noted. After long-term follow-up (median duration 24 months), half of the patients still had some chronic pain, but only 4 experienced acute relapse. CONCLUSION: This study suggests that IL-1ß inhibition may be an efficient therapeutic approach for acute HA flare, with a good safety profile.

[Reactive arthritis]. / Arthrite réactionnelle.

Reactive arthritis is usually regarded as a form of spondylarthritis. Patients generally present with an acute asymmetrical oligoarthritis following an episode of diarrhea or urethritis. The most frequent involved pathogens are Salmonella, Shigella, Campylobacter and Chlamydia trachomatis. Additional causative pathogens have been described. Non-steroidal anti-inflammatory drugs are the first line treatment for reactive arthritis, associated with physiotherapy. Occasionally, a short course of glucocorticoids or an intra-articular injection is needed. Chlamydia induced reactive arthritis should be treated with antibiotics. Some patients experience chronic persistent arthritis. These patients could benefit from a treatment with DMARDs such as sulfasalazine. In refractory cases, TNF-inhibitors are sometimes used.

L'arthrite réactionnelle est classée parmi les spondylo-arthropathies. Les patients présentent typiquement une oligoarthrite asymétrique suivant des diarrhées en cas d'infection à, par exemple, Salmonella ou Campylobacter ou suivant une infection urogénitale à Chlamydia trachomatis. Les patients peuvent aussi présenter des symptômes ophtalmiques ou cutanés. L'arthrite aiguë est traitée par anti-inflammatoires non stéroïdiens associés à de la physiothérapie. Des corticostéroïdes par voie intra-articulaire ou systémique sont parfois nécessaires. L'infection à Chlamydia trachomatis doit être traitée par antibiotiques. Chez une minorité de patients, l'arthrite devient chronique et nécessite l'introduction d'un traitement de fond, le plus souvent la sulfasalazine. Les anti-TNF sont parfois utilisés lorsque l'arthrite est réfractaire.

Comparison of ESSDAI and ClinESSDAI in potential optimisation of trial outcomes in primary Sjögren's syndrome: examination of data from the UK Primary Sjögren's Syndrome Registry.

OBJECTIVES: To assess the use of the Clinical EULAR Sjögren's Syndrome Disease Activity Index (ClinESSDAI), a version of the ESSDAI without the biological domain, for assessing potential eligibility and outcomes for clinical trials in patients with primary Sjögren's syndrome (pSS), according to the new ACR-EULAR classification criteria, from the UK Primary Sjögren's Syndrome Registry (UKPSSR). METHODS: A total of 665 patients from the UKPSSR cohort were analysed at their time of inclusion in the registry. ESSDAI and ClinESSDAI were calculated for each patient. RESULTS: For different disease activity index cut-off values, more potentially eligible participants were found when ClinESSDAI was used than with ESSDAI. The distribution of patients according to defined disease activity levels did not differ statistically (chi2 p = 0.57) between ESSDAI and ClinESSDAI for moderate disease activity (score ≥5 and <14; ESSDAI 36.4%; ClinESSDA 36.5%) or high disease activity (score ≥14; ESSDAI 5.4%; ClinESSDAI 6.8%). We did not find significant differences between the indexes in terms of activity levels for individual domains, with the exception of the articular domain. We found a good level of agreement between both indexes, and a positive correlation between lymphadenopathy and glandular domains with the use of either index and with different cut-off values. With the use of ClinESSDAI, the minimal clinically important improvement value was more often achievable with a one grade improvement of a single domain than with ESSDAI. We observed similar results when using the new ACR-EULAR classification criteria or the previously used American-European Consensus Group (AECG) classification criteria for pSS. CONCLUSIONS: In the UKPSSR population, the use of ClinESSDAI instead of ESSDAI did not lead to significant changes in score distribution, potential eligibility or outcome measurement in trials, or in routine care when immunological tests are not available. These results need to be confirmed in other cohorts and with longitudinal data.

The role of IL-1 in gout: from bench to bedside.

The translation of our knowledge of the biology of MSU crystal-induced IL-1 secretion gives rise to new targets and therapeutic strategies in the treatment of acute gout. The NACHT, LRR and PYD domains-containing protein 3 inflammasome is key to this, and is the subject of intense research. Novel pathways that modulate inflammasome activation, reactive oxygen species generation and extracellular processing of IL-1 have been described and show promise in in vitro and animal studies. Meanwhile, blocking IL-1 by various IL-1 inhibitors has shown the validity of this concept. Patients with acute gout treated with these inhibitors showed positive clinical and biological responses. More work needs to be performed to assess the risk/benefit profile of anti-IL-1 therapies as well as to identify those who will benefit the most from this novel approach to the treatment of gout.

Ultrasound can be useful to predict an evolution towards rheumatoid arthritis in patients with inflammatory polyarthralgia without anticitrullinated antibodies.

INTRODUCTION: Ultrasound (US) subclinical synovitis in prerheumatoid arthritis (RA) patients has been demonstrated in anticitrullinated antibodies (ACPA) positive patients to be predictive for future development of RA. The aim of the study was to assess the value of the US as a predictive factor for the future development of RA in patients with polyarthralgia without ACPA. METHOD: Eighty consecutive ACPA-patients with polyarthralgia without clinical synovitis or ACPA before the US examination were included. To detect significant US synovitis, we applied the criteria of a US score (SONAR) validated among RA patients and controls. The diagnosis of RA was based on the ACR/EULAR criteria. RESULTS: Significant US synovitis were present at baseline in 20 (25%) of the patients. The mean (SD) follow-up time was 18 (7) months in both groups. Seven (9%) patients developed a clear RA and 2 another inflammatory arthritis. US synovitis at baseline was significantly associated with evolution to RA: 5/20 (25%) versus 2/60 (3%) (P<0.05). The free time to RA was significantly shorter when US synovitis were present (P<0.01). Moreover, after multivariate analysis, US appeared to be the only independent predictor of an evolution to RA (OR: 7.4). Results remained similar after including all patients developing another inflammatory arthritis. CONCLUSIONS: Our study suggests that US can be used as a predictor for the evolution to RA or other inflammatory arthritis in patients presenting polyarthralgia without ACPA.

[Spondylarthropathies: conventional treatments and anti-TNF]. / Spondyloarthropathies: traitements conventionnels et anti-TNF.

Non-steroidal anti-inflammatory drugs (NSAID) are the first line treatment for spondylarthritis. NSAIDs are effective when used continuously or on demand, in short or long-term use. An effect on radiologic progression of the spine is still controversial. However, physicians have to be aware of potential cardiovascular, renal or gastro-intestinal secondary effects when prescribing NSAIDs. DMARDs like methotrexate or systemic corticosteroids are generally not recommended for the treatment of spondylarthritis. After NSAIDs failure, a TNF inhibitor can be used. 5 anti-TNF are available in Switzerland and they are all effective in this disease. Before starting an anti-TNF treatment, a screening is mandatory. Patients treated with an anti-TNF must be followed regularly.