ASDAS makes sense
but evidence needed
Dougados, professor of rheumatology at Cochin Hospital in Paris. Another piece currently lacking in the
case for treat-to-target is demonstration of the clinical benefit from
this approach in a trial, he added.
Outcome measures of disease
activity such as the ASDAS, as
well as the 28-joint Disease Activity Score for rheumatoid arthritis,
“are instrumental to reach the targets set” in a treat-to-target strategy, agreed Prof. Jürgen Braun,
professor of rheumatology and
medical director of the Rheumatology Center in Herne, Germany,
and another speaker during the
According to Prof. van der Heijde,
the other four recommendations
that now have evidence backup are:
• Define clinical remission or min-
imal disease as the absence of
clinical and laboratory evidence
of significant disease activity.
• An alternative treatment target
for PsA may be low or minimal
• Measure disease activity by clinical signs and symptoms and by
acute phase reactants.
• Once a treatment target is
reached it should be maintained.
The task force also outlined “an
extensive research agenda” where
evidence is needed, specifying
close to 50 individual research
topics. Among them Prof. van der
Heijde particularly called out the
role of the Health Assessment
Questionnaire (HAQ), validation of
PsA target outcomes, and better
parsing of the differences using remission or low disease activity as
the treatment target.
Prof. van der Heijde, Prof. Dougados, and Prof. Braun are all consultants for several drug companies.
The evidence we now have is the
difference between the new recommendations and the prior version. We have evidence from trials
in patients with psoriatic arthritis
using minimal disease activity as
a target. And we have indirect evidence from observational studies
in patients with SpA that suggest
the higher the ASDAS, the more
progression occurs. In addition,
results reported at the EULAR
2017 Congress showed that reductions in the ASDAS appeared
to correlate with the effect of a tumour necrosis factor inhibitor on
reduced radiographic progression
in patients with ankylosing spondylitis. But this is just an association; data from a randomised,
prospective trial should be available next year.
Although the data today are incomplete, I agree that the ASDAS
is the best measure we have for
disease activity in patients with axial SpA. Based on data reported at
EULAR, it seems that an ASDAS of
less than 1. 3 is the right target for
many axial SpA patients, although
every patient has a different target that must be individualised.
Every patient has a different
risk-and-benefit agenda; the target
must be very patient centred.
The recommendations say to
manage patients with axial SpA or
psoriatic arthritis by treating them
to a target. To do that a clinician
needs a standardised assessment
of a patient’s disease and to per-
form follow-up measurements to
see if the target is met. The data
Prof. Dougados cited from Paris
document that assessments such
as an ASDAS are rarely made.
Getting an ASDAS means knowing
either a patient’s C-reactive protein
level or erythrocyte sedimentation
rate. That requires blood work
before a clinic visit, something patients often don’t want.
Will these recommendations
change practice and make the ASDAS more widely used? That depends to some extent on whether
any benefits or penalties linked to
ASDAS use go into place.
Next year, we expect to see results from trials that are testing
whether the treat-to-target approach produces better outcomes.
Evidence like that will be important to further spur adoption.
Dr. Lianne S. Gensler is director of
the ankylosing spondylitis clinic at
the University of California, San
Francisco (USA). She has been a
consultant to Novartis and Janssen and has received research
support from AbbVie and UCB. Dr.
Gensler was a member of the task
force that issued the revised recommendations. She made these
comments in an interview.
Dr. Lianne S. Gensler