Biological DMARDs and disease modification in axial spondyloarthritis: a review through the lens of causal inference

被引:17
作者
Sepriano, Alexandre [1 ,2 ]
Ramiro, Sofia [2 ,3 ]
van der Heijde, Desiree [2 ]
Landewe, Robert [3 ,4 ]
机构
[1] Univ Nova Lisboa, NOVA Med Sch, Rheumatol, Lisbon, Portugal
[2] Leiden Univ, Rheumatol, Med Ctr, Leiden, Netherlands
[3] Zuyderland Med Ctr Heerlen, Rheumatol, Heerlen, Netherlands
[4] Univ Amsterdam, Med Ctr, Clin Immunol & Rheumatol, Dulvendrecht, Netherlands
来源
RMD OPEN | 2021年 / 7卷 / 02期
关键词
spondylitis; ankylosing; biological therapy; epidemiology; TUMOR-NECROSIS-FACTOR; SPINAL RADIOGRAPHIC PROGRESSION; ANKYLOSING-SPONDYLITIS; BONE-FORMATION; FACTOR INHIBITORS; ACTIVITY SCORE; INFLAMMATION; EXPOSURE; THERAPY; DAMAGE;
D O I
10.1136/rmdopen-2021-001654
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Axial spondyloarthritis (axSpA) is a chronic rheumatic disease characterised by inflammation predominantly involving the spine and the sacroiliac joints. In some patients, axial inflammation leads to irreversible structural damage that in the spine is usually quantified by the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). Available therapeutic options include biological disease-modifying antirheumatic drugs (bDMARDs), which have been proven effective in suppressing inflammation in several randomised controlled trials (RCT), the gold standard for evaluating causal treatment effects. RCTs are, however, unfeasible for testing structural effects in axSpA mainly due to the low sensitivity to change of the mSASSS. The available literature therefore mainly includes observational research, which poses serious challenges to the determination of causality. Here, we review the studies testing the effect of bDMARDs on spinal radiographic progression, making use of the principles of causal inference. By exploring the assumptions of causality under counterfactual reasoning (exchangeability, positivity and consistency), we distinguish between studies that likely have reported confounded treatment effects and studies that, on the basis of their design, have more likely reported causal treatment effects. We conclude that bDMARDs might, indirectly, interfere with spinal radiographic progression in axSpA by their effect on inflammation. Innovations in imaging are expected, so that placebo-controlled trials can in the future become a reality. In the meantime, causal inference analysis using observational data may contribute to a better understanding of whether disease modification is possible in axSpA.
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页数:11
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