TY - JOUR T1 - When Less Is More JF - The Journal of Rheumatology JO - J Rheumatol SP - 1089 LP - 1090 DO - 10.3899/jrheum.100333 VL - 37 IS - 6 AU - ATUL DEODHAR Y1 - 2010/06/01 UR - http://www.jrheum.org/content/37/6/1089.abstract N2 - Axial involvement is the hallmark of ankylosing spondylitis (AS), and it is unique in many ways among inflammatory arthritides. By its very anatomical location, it is difficult to assess clinically. Laboratory investigations including inflammatory markers are often unrevealing, and simple imaging such as radiographs remain normal for several years after the onset of the disease and change very slowly — if at all — later in the disease course1. Unlike their efficacy in other inflammatory arthritides, traditional disease-modifying antirheumatic drugs (DMARD) have been ineffective in improving function or reducing signs and symptoms of spinal involvement in AS. The significant efficacy of anti-tumor necrosis factor (TNF) agents in axial disease of AS is therefore even more striking2–5.With the limited therapeutic armamentarium for the management of spinal disease in AS (e.g., physical therapy, nonsteroidal antiinflammatory drugs), the use of anti-TNF agents is likely to grow, although the biggest hurdle remains their cost. A systematic review along with an economic evaluation of the use of the original 3 anti-TNF agents approved for the treatment of AS (etanercept, adalimumab, and infliximab) by the National Institute of Clinical Excellence (NICE) of Britain showed that the incremental cost-effectiveness ratios (ICER) of etanercept and adalimumab were roughly similar, falling below the conventional £30,000 (US $50,000) threshold per quality-adjusted life-year (QALY). However, the ICER for infliximab (IFX) used in the “approved” dose of 5 mg/kg every 6 weeks was in the … ER -