Diagnosing:Recognizing and proactively identifying patients with nr-axSpA
nr-axSpA criteria in patients with back pain for ≥3 months and age of onset <45 years53,54*
Sacroiliitis on imaging and ≥1 SpA feature
Active inflammation on MRI highly suggestive
of sacroiliitis associated with SpA
HLA-B27+ and ≥2 other SpA features
ASAS classification criteria were developed to identify patients with axSpA (nr-axSpA and AS).53*
Probability of diagnosis53,55,56
The clinical diagnosis of axSpA (nr-axSpA and AS) relies upon a combination of SpA features and imaging.55
The percentages below indicate the percentage of patients who are eventually diagnosed with nr-axSpA.
Among patients with chronic back pain in GP/PCP office:
The first step to evaluating a patient with chronic back pain for axSpA is to determine whether the back pain is inflammatory or mechanical in nature57
Presence of IBP†:
IBP is characterized by age at onset <40, insidious onset, improvement with exercise, no improvement with rest, and pain at night with improvement upon getting up53,55
Presence of one or two additional SpA features†:
Evaluate the patient for the presence of SpA features, including enthesitis, dactylitis, uveitis, a positive family history of SpA, CD, alternating buttock pain, psoriasis, asymmetrical arthritis, a positive response to NSAIDs, and an elevated ESR or CRP to evaluate inflammation53
Positive HLA-B27 test result is associated with an increased likelihood that the patient has axSpA53
At least three axSpA features will increase the probability to 80% to 95%55
Imaging: X-ray SIJ (+) = AS57
X-ray SIJ (–), MRI SIJ (+) = nr-axSpA57
Prevalence of extraspinal manifestations in nr-axSpA patients‡
Enthesitis up to 44%58
Peripheral arthritis up to 41%58
Psoriasis up to 11%37
Subclinical IBD up to 42%59
Uveitis up to 12%53
Dactylitis up to 7%53
*Derived from full ASAS axSpA classification criteria, which differentiates criteria for nr-axSpA and AS. †Probability varies based on number of SpA features present. ‡Prevalence includes all axial and peripheral SpA disease states.
AS: ankylosing spondylitis; ASAS: Assessment of SpondyloArthritis international Society; CD: Crohn’s disease; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; GP: general practitioner; HLA-B27+: human leukocyte antigen-B27 positive; IBD: inflammatory bowel disease; IBP: inflammatory back pain; MRI: magnetic resonance imaging; nr-axSpA: non-radiographic axial spondyloarthritis; NSAID: nonsteroidal anti-inflammatory drug; PCP: primary care physician; SIJ: sacroiliac joint; SpA: spondyloarthritis.
CIMZIA is indicated for the treatment of adults with moderately to severely active rheumatoid arthritis (RA)
CIMZIA is indicated for the treatment of adult patients with active psoriatic arthritis (PsA)
CIMZIA is indicated for the treatment of adult patients with active ankylosing spondylitis (AS)
CIMZIA is indicated for reducing signs and symptoms of Crohn's disease (CD) and maintaining clinical response in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy
CIMZIA is indicated for the treatment of adults with moderate-to-severe plaque psoriasis (PSO) who are candidates for systemic therapy or phototherapy
CIMZIA is indicated for the treatment of adults with active non-radiographic axial spondyloarthritis (nr-axSpA) with objective signs of inflammation
Important Safety Information
CIMZIA is contraindicated in patients with a history of hypersensitivity reaction to certolizumab pegol or to any of the excipients. Reactions have included angioedema, anaphylaxis, serum sickness, and urticaria.
Patients treated with CIMZIA are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids.
Discontinue CIMZIA if a patient develops a serious infection or sepsis.
Reported infections include:
Active tuberculosis (TB), including reactivation of latent TB. Patients with TB have frequently presented with disseminated or extrapulmonary disease. Test patients for latent TB before CIMZIA use and during therapy. Initiate treatment for latent TB prior to CIMZIA use.
Invasive fungal infections, including histoplasmosis, coccidioidomycosis, candidiasis, aspergillosis, blastomycosis, and pneumocystosis. Patients with histoplasmosis or other invasive fungal infections may present with disseminated, rather than localized, disease. Antigen and antibody testing for histoplasmosis may be negative in some patients with active infection. Consider empiric anti-fungal therapy in patients at risk for invasive fungal infections who develop severe systemic illness.
Bacterial, viral, and other infections due to opportunistic pathogens, including Legionella and Listeria.
Carefully consider the risks and benefits of treatment with CIMZIA prior to initiating therapy in the following patients: with chronic or recurrent infection; who have been exposed to TB; with a history of opportunistic infection; who resided in or traveled in regions where mycoses are endemic; with underlying conditions that may predispose them to infection. Monitor patients closely for the development of signs and symptoms of infection during and after treatment with CIMZIA, including the possible development of TB in patients who tested negative for latent TB infection prior to initiating therapy.
Do not start CIMZIA during an active infection, including localized infections.
Patients older than 65 years, patients with co-morbid conditions, and/or patients taking concomitant immunosuppressants may be at greater risk of infection.
If an infection develops, monitor carefully and initiate appropriate therapy.
Lymphoma and other malignancies, some fatal, have been reported in children and adolescent patients treated with TNF blockers, of which CIMZIA is a member. CIMZIA is not indicated for use in pediatric patients.
Consider the risks and benefits of CIMZIA treatment prior to initiating or continuing therapy in a patient with known malignancy.
In clinical trials, more cases of malignancies were observed among CIMZIA-treated patients compared to control patients.
In CIMZIA clinical trials, there was an approximately 2-fold higher rate of lymphoma than expected in the general U.S. population. Patients with rheumatoid arthritis, particularly those with highly active disease, are at a higher risk of lymphoma than the general population.
Malignancies, some fatal, have been reported among children, adolescents, and young adults being treated with TNF blockers. Approximately half of the cases were lymphoma, while the rest were other types of malignancies, including rare types associated with immunosuppression and malignancies not usually seen in this patient population.
Postmarketing cases of hepatosplenic T-cell lymphoma (HSTCL), a rare type of T-cell lymphoma, have been reported in patients treated with TNF blockers, including CIMZIA. These cases have had a very aggressive disease course and have been fatal. The majority of reported TNF blocker cases have occurred in patients with Crohn’s disease or ulcerative colitis, and the majority were in adolescent and young adult males. Almost all of these patients had received treatment with azathioprine or 6-mercaptopurine concomitantly with a TNF blocker at or prior to diagnosis. Carefully assess the risks and benefits of treating with CIMZIA in these patient types.
Cases of acute and chronic leukemia were reported with TNF blocker use.
Worsening and new onset congestive heart failure (CHF) have been reported with TNF blockers. Exercise caution and monitor carefully.
Angioedema, anaphylaxis, dyspnea, hypotension, rash, serum sickness, and urticaria have been reported following CIMZIA administration. If a serious allergic reaction occurs, stop CIMZIA and institute appropriate therapy. The needle shield inside the removable cap of the CIMZIA prefilled syringe contains a derivative of natural rubber latex which may cause an allergic reaction in individuals sensitive to latex.
hepatitis b virus reactivation
Use of TNF blockers, including CIMZIA, may increase the risk of reactivation of hepatitis B virus (HBV) in patients who are chronic carriers. Some cases have been fatal.
Test patients for HBV infection before initiating treatment with CIMZIA.
Exercise caution in patients who are carriers of HBV and monitor them before and during CIMZIA treatment.
Discontinue CIMZIA and begin antiviral therapy in patients who develop HBV reactivation. Exercise caution when resuming CIMZIA after HBV treatment.
TNF blockers, including CIMZIA, have been associated with rare cases of new onset or exacerbation of central nervous system and peripheral demyelinating diseases, including multiple sclerosis, seizure disorder, optic neuritis, peripheral neuropathy, and Guillain-Barré syndrome.
Rare reports of pancytopenia, including aplastic anemia, have been reported with TNF blockers. Medically significant cytopenia has been infrequently reported with CIMZIA.
Consider stopping CIMZIA if significant hematologic abnormalities occur.
Do not use CIMZIA in combination with other biological DMARDS.
Treatment with CIMZIA may result in the formation of autoantibodies and, rarely, in development of a lupus-like syndrome. Discontinue treatment if symptoms of a lupus-like syndrome develop.
Patients on CIMZIA should not receive live or live-attenuated vaccines.
The most common adverse reactions in CIMZIA clinical trials (≥8%) were upper respiratory infections (18%), rash (9%), and urinary tract infections (8%).
Keystone E, van der Heijde D, Mason D Jr, et al. Certolizumab pegol plus methotrexate is significantly more effective than placebo plus methotrexate in active rheumatoid arthritis: findings of a fifty-two–week, phase III, multicenter, randomized, double-blind, placebo-controlled, parallel-group study. Arthritis Rheum. 2008;58:3319-3329.
Schwartzman S, Morgan GJ Jr. Does route of administration affect the outcome of TNF antagonist therapy? Arthritis Res Ther. 2004;6(Suppl 2):Section 19-Section 23.
Sheikhzadeh A, Yoon J, Formosa D, et al. The effect of a new syringe design on the ability of rheumatoid arthritis patients to inject a biological medication. Appl Ergon. 2012;43:368-375.
Data on file. UCB, Inc.; Smyrna, GA.
Rheumatology References (including RA, PsA and AS; nr-axSpA references are listed below)
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