Based on new evidence and an expert consensus, the American College of Rheumatology (ACR), the Spondylitis Association of America, and the Spondyloarthritis Research and Treatment Network released updated recommendations for the treatment of axial spondyloarthritis (SpA), which comprises ankylosing spondylitis (AS) and nonradiographic axial SpA. This report was published in Arthritis Care & Research.

A systematic review of literature focused on treatment and management strategies for AS and nonradiographic axial SpA was performed. Quality of evidence and subsequent recommendations were rated using the Grading of Recommendations, Assessment, Development and Evaluation methodology; final recommendations were formulated and voted on by an expert panel, and consensus required at least 70% agreement among voters.

Recommendations for the Treatment of Active AS

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

ACR strongly recommends that patients with active AS receive treatment with NSAIDs over no treatment with NSAIDs, and conditionally recommends continuous treatment over on-demand treatment with NSAIDs; no preferred choice of NSAIDs is recommended.

Sulfasalazine, Methotrexate, Tofacitinib

Regardless of NSAID treatment, ACR conditionally recommends that adults with active AS be treated with sulfasalazine, methotrexate, or tofacitinib over no treatment; sulfasalazine and methotrexate should only be considered in patients with prominent peripheral arthritis or when tumor necrosis factor inhibitors (TNFi) are not available.

Secukinumab, Ixekizumab

Despite treatment with NSAIDs, ACR strongly recommends treatment with secukinumab or ixekizumab over no treatment, and conditionally recommends treatment with secukinumab or ixekizumab over treatment with tofacitinib.

TNFi

Despite treatment with NSAIDs, ACR strongly recommends treatment with TNFi over no treatment with TNFi, and conditionally recommends TNFi over treatment with tofacitinib, secukinumab, or ixekizumab; no particular TNFi is recommended as the preferred choice.

Adults with active AS who have contraindications to TNFi should conditionally receive treatment with secukinumab or ixekizumab over treatment with sulfasalazine, methotrexate, or tofacitinib; secukinumab or ixekizumab are also conditionally recommended over treatment with a different TNFi in patients with primary nonresponse to TNFi.

In patients with secondary nonresponse to TNFi, ACR conditionally recommends treatment with a different TNFi over treatment with a non-TNFi biologic. Regardless of response to the first TNFi used, ACR recommends against switching to treatment with a biosimilar of the first TNFi; treatment with sulfasalazine or methotrexate in favor of treatment with a new biologic is also recommended.

Glucocorticoids

ACR strongly recommends against treatment with systemic glucocorticoids. In adults with active sacroiliitis or stable axial disease with active enthesitis or peripheral arthritis, treatment with locally administered parenteral glucocorticoids are conditionally recommended over no treatment with local glucocorticoids. Peritendon injections of Achilles, patellar, and quadriceps tendons should be avoided.

Physical Therapy

Physical therapy is strongly recommended over no physical therapy in patients with active AS; ACR recommends active interventions (supervised exercise) over passive interventions (massage, ultrasound, heat), and land-based physical therapy over aquatic therapy interventions.

Recommendations for the Treatment of Stable AS

NSAIDs

In patients with stable AS, ACR conditionally recommends on-demand treatment with NSAIDs over continuous treatment with NSAIDs; no preferred choice of NSAIDs is recommended.

TNFi

In adults receiving treatment with TNFi and NSAIDs, ACR conditionally recommends continuing with TNFi alone over continuing both treatments. Similarly, for patients receiving TNFi and conventional synthetic antirheumatic drugs, continuing with TNFi alone is recommended. ACR strongly recommends that adults treated with an originator TNFi continue with it rather than switching to the originator TNFi’s biosimilar.

Biologics

In adults with stable AS who receive treatment with a biologic, ACR conditionally recommends against discontinuation or tapering of the biologic dose as a standard of care.

Physical Therapy

Treatment with physical therapy is strongly recommended over no physical therapy in patients with stable AS.

Recommendations for Adults With Active or Stable AS

ACR conditionally recommends against concomitant treatment with TNFi and low-dose methotrexate in adults with active or stable AS.

Unsupervised back exercises are conditionally advised; however, spinal manipulation is strongly recommended against in patients with spinal fusion or spinal osteoporosis.

Fall evaluation and counseling are conditionally recommended for all adults with AS, along with participation in formal group or individual self-management education.

Total hip arthroplasty is strongly recommended over no surgical treatment in patients with advanced hip arthritis, but ACR recommends against elective spinal osteotomy in adults with severe kyphosis.

Recommendations for Adults With AS-Related Comorbidities

In adults with comorbid acute iritis, ACR strongly recommends treatment by an ophthalmologist to help decrease disease severity, duration, or complications.

In adults with comorbid recurrent iritis, prescription of topical glucocorticoids — used at home to promptly reduce the severity and duration of eye symptoms — is conditionally recommended by the ACR over no prescription. Furthermore, TNFi monoclonal antibodies are conditionally recommended over other biologics to treat recurrent iritis.

In adults with comorbid inflammatory bowel disease, ACR does not recommend any particular choice of NSAID to attenuate the risk of worsening symptoms; however, treatment with TNFi monoclonal antibodies over other biologics is conditionally recommended for these patients.

Recommendations for Adults With Active Nonradiographic Axial SpA

NSAIDs

ACR strongly recommends for patients with active nonradiographic axial SpA treatment with NSAIDs over no treatment with NSAIDs, and conditionally recommends continuous treatment over on-demand treatment with NSAIDs; no preferred choice of NSAIDs is recommended.

Sulfasalazine, Methotrexate, Tofacitinib

Regardless of NSAID treatment, ACR conditionally recommends adults with active nonradiographic axial SpA be treated with sulfasalazine, methotrexate, or tofacitinib over no treatment with these medications.

Secukinumab, Ixekizumab

Despite treatment with NSAIDs, ACR strongly recommends treatment with secukinumab or ixekizumab over no treatment with these medications, and conditionally recommends treatment with secukinumab or ixekizumab over treatment with tofacitinib.

TNFi

Irrespective of NSAID treatment, ACR strongly recommends treatment with TNFi over no treatment with TNFi, and conditionally recommends TNFi over treatment with tofacitinib, secukinumab, or ixekizumab; no particular TNFi is recommended as the preferred choice.

Adults with active nonradiographic axial SpA who have contraindications to TNFi should conditionally receive treatment with secukinumab or ixekizumab over treatment with sulfasalazine, methotrexate, or tofacitinib; secukinumab or ixekizumab are also conditionally recommended over treatment with a different TNFi in patients with primary nonresponse to TNFi.

In patients with secondary nonresponse to TNFi, ACR conditionally recommends treatment with a different TNFi over treatment with a non-TNFi biologic. Regardless of response to the first TNFi used, ACR strongly recommends against switching to treatment with a biosimilar of the first TNFi. Finally, treatment with sulfasalazine or methotrexate is recommended against, in favor of treatment with a different biologic.

Glucocorticoids

ACR strongly recommends against treatment with systemic glucocorticoids. In adults with active sacroiliitis, local glucocorticoid therapy is recommended over no treatment with local glucocorticoids. In adults with active enthesitis or peripheral arthritis, treatment with locally administered parenteral glucocorticoids is conditionally recommended over no treatment with local glucocorticoids. Peritendon injections of Achilles, patellar, and quadriceps tendons should be avoided.

Physical Therapy

Physical therapy is strongly recommended over no physical therapy in patients with active nonradiographic axial SpA; ACR recommends active interventions (supervised exercise) over passive interventions (massage, ultrasound, heat), and land-based physical therapy over aquatic therapy interventions.

Recommendations for Adults With Stable Nonradiographic Axial SpA

NSAIDs

In patients with stable nonradiographic axial SpA, ACR conditionally recommends on-demand treatment with NSAIDs over continuous treatment with NSAIDs; no preferred choice of NSAIDs is recommended.

TNFi

In adults receiving treatment with TNFi and NSAIDs, ACR conditionally recommends continuing with TNFi alone over continuing both treatments. Similarly, for patients receiving TNFi and conventional synthetic antirheumatic drugs, it is recommended to continue with TNFi alone. ACR strongly recommends that adults treated with an originator TNFi continue with it rather than switching to the originator TNFi’s biosimilar.

Biologics

In adults with stable nonradiographic axial SpA who receive treatment with a biologic, ACR conditionally recommends against discontinuation or tapering of the biologic dose as a standard of care.

Recommendations for Adults With Active or Stable Nonradiographic Axial SpA

ACR conditionally recommends against concomitant treatment with TNFi and low-dose methotrexate in adults with active or stable nonradiographic axial SpA.

Recommendations for Disease Activity Assessment, Imaging, and Screening

Disease Activity Assessment

ACR recommends to clinicians the use of a validated AS disease activity measure at regular intervals for monitoring disease activity, and conditionally recommends the regular monitoring of C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) concentrations over usual care without CRP or ESR monitoring.

In patients with active AS or nonradiographic axial SpA, a treat-to-target strategy using a target of AS Disease Activity Score (DAS) <1.3 (or 2.1) is conditionally recommended against, in favor of a treatment strategy based on physician assessment.

Imaging

ACR conditionally recommends obtaining a spinal or pelvis MRI to assess disease activity in adults with AS or nonradiographic axial SpA being treated with a biologic and for whom disease activity is unclear. In adults with stable AS or nonradiographic axial SpA activity, a spinal or pelvic MRI is conditionally recommended against to confirm disease inactivity.

In patients with active or stable AS or nonradiographic axial SpA on any treatment, ACR conditionally recommends against obtaining repeat spine radiographs at regular intervals as a standard of care.

Screening

In adults with AS, ACR conditionally recommends screening for osteopenia/osteoporosis with a dual x-ray absorptiometry (DXA) scan over no screening; in patients with spinal fusion or syndesmophytes, screening for osteoporosis/osteopenia with a DXA scan is conditionally recommended for the spine as well as the hips, compared with obtaining a DXA scan of only the hip or other nonspine sites.

In addition, for patients with AS, ACR strongly recommends against screening for cardiac conduction defect or valvular heart disease with electrocardiograms.

Disclosures: Multiple authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Ward MM, Deodhar A, Gensler LS, et al. 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis [published online August 21, 2019]. Arthritis Care Res. doi:10.1002/acr.24025