Therapie der ankylosierenden Spondylitis mit nichtsteroidalen Antirheumatika und Biologika

Zusammenfassung

Nichtsteroidale Antirheumatika (NSAR) werden seit vielen Jahren mit Erfolg als „first-line-Therapie” in der Behandlung der Spondylitis ankylosans (AS) eingesetzt. Es können hier unselektive COX-Hemmer oder selektive COX-2-Hemmer eingesetzt werden, die hinsichtlich der Wirksamkeit als gleichwertig einzustufen sind. Bei der Differenzialindikation sind hier vor allem die gastrointestinale und kardiovaskuläre Toxizität der Präparate zu beachten. Bei begleitender chronisch entzündlicher Darmerkrankung sollten COX-2-Hemmer wie Etoricoxib gegeben werden. Es gibt Hinweise, dass eine kontinuierliche Gabe von NSAR die radiologische Progression der Erkrankung aufhalten kann. Dieser Befund wird zur Zeit in einer großen Studie überprüft. Die TNF-alpha-Blocker sind als Meilenstein in der Therapie der AS anzusehen. Alle drei zugelassenen Präparate sind sowohl in der Kurzzeit- als auch in der Langzeittherapie der AS wirksam. Nach Absetzen der TNF-alpha-Blocker ist in einem hohen Prozentsatz mit Krankheitsrezidiven zu rechnen, so dass die Behandlung als Dauertherapie konzipiert werden muss. Ob eine Behandlung mit TNF-Blockern die radiologische Progression aufhalten kann, ist noch nicht abschließend geklärt. Auf Infektionen, unter anderem Tuberkulose, muss vor und während der Behandlung geachtet werden.

Summary

Nonsteroidal antiinflammatory drugs (NSAIDs) have been used successfully as„ first line therapy” of ankylosing spondylitis (AS) for many years. Unselective NSAIDs and the Coxibes are equally effective in the treatment of AS. When choosing one of these substances gastrointestinal and cardiovascular toxicities of unselective NSAIDs and Coxibes must be considered. Coxibes such as etoricoxib should be used preferentially in patients with concomitant inflammatory bowel disease. A continuous therapy with NSAIDs seems to decelerate radiologic progression of AS. This finding is now re-evaluated in a large clinical trial. TNF-alpha blockers must be regarded as milestones in the therapy of AS. All three approved substances etanercept, infliximab and adalimumab are effective in the short term therapy as well as in the long term therapy of AS. After withdrawal of TNF blockers almost all patients relapse, therefore TNF blockers should be given continuously. There is no final answer to the question whether TNF blockers are able to decelerate radiologic progression of AS. Before and during therapy one has to look for infections, especially tuberculosis.

Schlüsselwörter

Spondylitis ankylosans - nichtsteroidale Antirheumatika - Biologika - TNF-alpha-Blocker

Keywords

Ankylosing spondylitis - nonsteroidal antiinflammatory drugs - biologicals - TNF-alpha blockers

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