Therapeutic Controversies Tumor Necrosis Factor α Inhibitors in Ankylosing Spondylitis

Tumor necrosis factor a inhibitors (TNF blockers) have revolutionized the treatment of patients with ankylosing spondylitis. Despite clinical efficacy, there are questions and controversies treating rheumatologists face, which this review discusses: whether there are specific indications for specific TNF blockers; whether the dose of TNF blockers can be decreased; whether immunogenicity plays a role; what the role of residual active inflammation on MRI might be; and whether there is a window of opportunity to treat patients with ankylosing spondylitis and prevent radiographic progression. This article also summarizes evidence for switching between TNF blockers and addresses the question of malignancies.