Treatment with nonsteroidal antiinflammatory drugs (
NSAID) is the recommended first-line
therapy in patients with
axial spondyloarthritis (
axSpA); and for those patients who have persistently active disease, the introduction of
tumor necrosis factor-α (TNF-α) inhibitors is indicated. Conventional nonbiological
disease-modifying antirheumatic drugs (
DMARD), although effective and used in clinical practice for peripheral
arthritis, are not recommended. Few studies have been conducted with the aim of evaluating the effect of conventional
DMARD, either alone or in combination, in
axSpA. As for
psoriatic arthritis (PsA),
DMARD are widely used, but few trials are available about their effects on axial involvement, which is not often assessed as a primary outcome in clinical trials. In
rheumatoid arthritis, combination
therapy of 2 or more conventional
DMARD appears to confer better response than
methotrexate monotherapy, and may even be a viable alternative to TNF-α inhibitors. In peripheral PsA, combination
therapy can be used
after treatment failure with 1
DMARD, but few studies have been conducted. However, available evidence for the combination of conventional
DMARD indicates a lack of any significant benefit on axial symptoms; thus this treatment approach does not represent an effective alternative to anti-TNF-α
therapy.