“A patient unresponsive to potent medications such as tumor necrosis factor-alpha inhibitors (TNF-α inhibitors) or interleukin-17A (IL-17A) experienced noteworthy pain relief within a mere week of taking Rinvoq (upadacitinib). This rapid response outpaces the typical two-week timeframe associated with disease activity improvement. While the precise mechanism remains unclear, it is hypothesized that the blockade of cytokines responsible for inflammation also inhibits those contributing to pain. This dual action may have led to effective pain control.” 

As health insurance increasingly covers numerous medications for ankylosing spondylitis, a condition for which current treatments have often fallen short, AbbVie's JAK inhibitor Rinvoq is gaining popularity among clinicians due to its convenience and efficacy.

For patients grappling with ankylosing spondylitis, characterized by stiffness and sleep-disrupting pain, the prospect of alleviating discomfort within a mere week of treatment represents a significant and crucial option for healthcare providers.

Hong Seung-jae, a professor of rheumatology at Kyung Hee University Hospital and the insurance director of the Korean College of Rheumatology (KCR), shared these insights during a press conference organized by AbbVie Korea in Seoul. The conference took place on Wednesday to mark the inclusion of Rinvoq, a selective and reversible JAK1 inhibitor, in insurance coverage for severe active ankylosing spondylitis.

Ankylosing spondylitis is an autoimmune disease marked by inflammation initiating in the sacroiliac joints, leading to the fusion of the spine's vertebrae. The inflammatory process can extend upward, affecting the thoracic and cervical vertebrae. Although individuals may experience temporary relief while in motion, immobility during sleep contributes to stiffness and morning pain. Activities like bending over or changing positions, even while lying on your side, can become challenging for those affected.

According to the Korea Health Insurance Review and Assessment Service (HIRA), the count of patients seeking medical attention for ankylosing spondylitis (coded as M45) rose by 22 percent over five years, from 41,797 in 2017 to 51,106 in 2021. The prevalence of the disease was notably higher among men, outnumbering women at a ratio of 2.5 to 1. Ankylosing spondylitis is particularly prevalent among young men, with 56 percent of cases occurring in the 20s-40s age group.

Hong emphasized that the primary objective in treating ankylosing spondylitis is to sustain remission, defined as the clinical absence of inflammation. Attaining this goal involves non-drug interventions like exercise and physical therapy. Additionally, a three-month course of non-steroidal anti-inflammatory drugs (NSAIDs) is often prescribed to mitigate inflammation and alleviate pain. In cases where these measures prove ineffective, immunomodulators (TNF-α inhibitors), biologics, and JAK inhibitors may be incorporated into the treatment plan.

Despite the positive impact of TNF-α inhibitors on patients for almost two decades, Hong noted that a significant number of patients do not experience long-term benefits from their use.

In response, the Ministry of Health and Welfare expanded health insurance coverage for ankylosing spondylitis drugs starting this month. Oral JAK inhibitors, including AbbVie’s Rinvoq and Pfizer's Xeljanz (tofacitinib), and IL-17A inhibitors, including Lilly’s Taltz (ixekizumab) and Novartis’ Cosentyx (secukinumab), have become recently reimbursable. 

Rinvoq is eligible for reimbursement for patients diagnosed with severe active ankylosing spondylitis who have not responded adequately to one or more TNF-α inhibitors or IL-17A inhibitors or have discontinued treatment due to side effects.

"In the realm of limited treatment choices for those dealing with ankylosing spondylitis, Rinvoq has proven, in real-world studies, to be effective in bringing about substantial remission and pain relief, whether used on its own or alongside biologics. The added convenience of a once-daily oral dose makes it even more attractive," explained Hong. "And now, with insurance covering Rinvoq, patients have more options for their treatment."

For rheumatoid arthritis, there are four approved medications, and if one proves ineffective, switching to another is restricted, Hong went on to say. 

Conversely, with ankylosing spondylitis, if one JAK inhibitor doesn't work, switching to a different one is now allowed, and reimbursement is possible. 

“This shift is expected to positively influence clinical practices, and we appreciate the forward-looking decision made by the HIRA,” he said.

This is when you suspect ankylosing spondylitis

Hong stressed the importance of early diagnosis and treatment to enhance the quality of life for individuals with ankylosing spondylitis before it progresses to a severe stage. Specifically, without early intervention, ankylosing spondylitis may trigger inflammation in other organs, potentially resulting in complications.

Hence, capturing images of the pelvic region, the initial site of ankylosing spondylitis development, is crucial. If an X-ray primarily targets the lower back during back pain assessment, it may lead to a missed early diagnosis since the pelvis remains unseen in this approach.

“When young people come to us with back pain, we recommend that we take a pelvic or sacroiliac joint X-ray to show the pelvis during the imaging examination,” Hong said.

He noted that it is not uncommon for back pain to be mistaken for a herniated disc.

The simplest way to differentiate between discs and ankylosing spondylitis is that spondylitis tends to be comfortable during movement and painful when at rest, whereas disc-related issues are usually comfortable when at rest and painful during movement, according to Hong.

For this reason, Hong suggests checking whether your back pain, particularly in the hip area, initiated before the age of 40, if it's worsening over time, if resting doesn't alleviate it, if physical activity improves or exacerbates the pain, and if you experience nocturnal back pain. 

Additionally, he suggested a self-assessment checklist that includes peripheral joint pain in your extremities alongside back pain, a history of uveitis (painful and bleeding eye condition), or pain in the Achilles ligament located in the heel.

"If you affirm four or more of these questions, it's advisable to consult with a rheumatologist," he said.