Assessment of patients with spondyloarthropathies for treatment with tumour necrosis factor blockade

Department of Rheumatology, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ, UK.1Present address: Department of Rheumatology, St Thomas' Hospital, London SE1 7EH, UK There is no doubt that the arrival and licensing of two tumour necrosis factor (TNF)-blocking drugs—infliximab and etanercept—for the treatment of ankylosing spondylitis (AS) represents the first major advance in the treatment of this condition since the advocacy of exercises and the introduction of phenylbutazone. These agents have also been shown unequivocally to be effective in a proportion of patients with psoriatic arthritis (PsA), comparable to their effect in rheumatoid arthritis (RA), and anecdotal reports also suggest benefits for patients with enteropathic arthritis, persistent reactive arthritis (ReA) and undifferentiated spondyloarthropathy (SpA). But, as with RA, the availability of these agents places a huge responsibility upon rheumatologists, individually and collectively, to negotiate the poorly charted waters of assessment of disease outcomes, known and potential drug toxicity and potentially massive cost. Moreover, all parties to the negotiation are signed up to the provision of such treatment according to criteria that are wise, transparent and fair.