1 Recommendations

1.1 Secukinumab is recommended as an option for treating active non-radiographic axial spondyloarthritis with objective signs of inflammation (shown by elevated C-reactive protein or MRI) that is not controlled well enough with non-steroidal anti-inflammatory drugs (NSAIDs) in adults. It is recommended only if:

tumour necrosis factor (TNF)-alpha inhibitors are not suitable or do not control the condition well enough and
the company provides secukinumab according to the commercial arrangement.

1.2 Assess response to secukinumab after 16 weeks of treatment. Continue treatment only if there is clear evidence of response, defined as:

a reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score to 50% of the pre-treatment value or by 2 or more units and
a reduction in the spinal pain visual analogue scale (VAS) by 2 cm or more.

1.3 Take into account any communication difficulties, or physical, psychological, sensory or learning disabilities that could affect responses to the BASDAI and spinal pain VAS questionnaires, and make any appropriate adjustments.

1.4 These recommendations are not intended to affect treatment with secukinumab that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

Why the committee made these recommendations

Treatment for non-radiographic axial spondyloarthritis that is not controlled well enough with NSAIDs is limited to TNF-alpha inhibitors (adalimumab, certolizumab pegol, etanercept and golimumab). There are no treatment options when people cannot have TNF-alpha inhibitors, or if TNF-alpha inhibitors have not worked well enough.

Clinical trial evidence shows that secukinumab is effective compared with placebo. There are no trials directly comparing secukinumab with TNF-alpha inhibitors. But an indirect comparison suggests that secukinumab may be less effective than TNF‑alpha inhibitors. However, this evidence is uncertain.

Different TNF-alpha inhibitors have different costs but similar effectiveness. When more than one TNF-alpha inhibitor is suitable, the cheapest is used, currently adalimumab biosimilar. Because of this, secukinumab is not a cost-effective use of NHS resources when compared with TNF-alpha inhibitors. Secukinumab is only considered to be cost effective for people who cannot have TNF-alpha inhibitors, or when TNF-alpha inhibitors have not worked well enough. Therefore, it is recommended in these situations.