Ankylosing Spondylitis

Publication Date: August 22, 2019

Key Points

Key Points

  • Axial spondyloarthritis (SpA), comprising ankylosing spondylitis (AS) and nonradiographic axial SpA, is the main form of chronic inflammatory arthritis affecting the axial skeleton.
  • AS affects 0.1–0.5% of the population and is characterized by inflammatory back pain, radiographic sacroiliitis, excess spinal bone formation, and a high prevalence of HLA–B27.
  • The severity of arthralgia, stiffness, and limited flexibility varies widely among patients and over the course of axial SpA.
  • Skeletal disease may be accompanied by uveitis, psoriasis, and inflammatory bowel disease (IBD).
  • The goals of treatment are to alleviate symptoms, improve functioning, maintain the ability to work, decrease disease complications, and forestall skeletal damage as much as possible.

Table 1. Definitions of Key Terms

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Term

Definition

Active disease

Disease causing symptoms at an unacceptably bothersome level to the patient and judged by the examining clinician to be due to inflammation.

Stable disease

Disease that was asymptomatic or causing symptoms but at an acceptable level as reported by the patient. A minimum of 6 months was required to qualify as clinically stable.

Primary nonresponse

Absence of a clinically meaningful improvement in disease activity over the 3 to 6 months after treatment initiation, not related to toxicity or poor adherence.

Secondary nonresponse

Recurrence of ankylosing spondylitis activity, not due to treatment interruption or poor adherence, after having a sustained clinically meaningful improvement on treatment (generally, beyond the initial 6 months of treatment).

Conventional synthetic antirheumatic drug

Sulfasalazine, methotrexate, leflunomide, apremilast, thalidomide, pamidronate.

Biosimilar

Biopharmaceuticals that are copies of an original biologic medication and tested to be of the same purity and potency as the original. In these recommendations, we refer only to TNFi biosimilars. Examples include infliximab-dyyb, etanercept-szzs, and adalimumab-atto.

TNFi

Infliximab, etanercept, adalimumab, certolizumab, golimumab, and their biosimilars.

TNFi monoclonal antibodies

Infliximab, adalimumab, certolizumab, golimumab.

Biologics

TNFi, abatacept, rituximab, sarilumab, tocilizumab, ustekinumab, secukinumab, ixekizumab

Patient preferences

Beliefs and expectations regarding potential benefits and harms of treatment and how these relate to an individual’s goals for health and life.

Shared decision-making

The process by which a patient and clinician arrive at an individualized treatment decision based on an understanding of the potential benefits and risks of available treatment options and of a patient’s values and preferences.


Treatment

Treatmen...

...s for the Treatment of Adults With A...

...y recommend treatment with NSAIDs over...

...ionally recommend continuous treatment...

.... We do not recommend any particular...

...ts with active AS despite treatment with NSAIDs,...

...In adults with active AS despite treatment with N...

...adults with active AS despite treatment with N...

...recommend any particular TNFi as the p...

...with active AS despite treatment with NSAIDs...

...In adults with active AS despite treatment with N...

...ith active AS despite treatment with NSAI...

...1. In adults with active AS despite t...

...In adults with active AS despite treatment...

...In adults with active AS despite treat...

...dults with active AS despite treatment...

...ith active AS despite treatment with th...

16. We strongly recommend against treatment wit...

...th isolated active sacroiliitis despite trea...

...with stable axial disease and active en...

...with stable axial disease and active peripher...

...rongly recommend treatment with physical therapy...

...onditionally recommend active physical therapy in...

...itionally recommend land-based physical th...

Recommendations for Adults With...

...ally recommend on-demand treatment with NS...

.... In adults receiving treatment with...

25. In adults receiving treatment with TN...

...receiving treatment with a biologic, we cond...

...ceiving treatment with a biologic, we conditio...

...eceiving treatment with an originator TNFi, we st...

...y recommend treatment with physical...

...tions for Adults With Active or Stable AS...

...n adults receiving treatment with TN...

31. We conditionally recommend advi...

...e conditionally recommend fall eva...

33. We conditionally recommend participation i...

...4. In adults with spinal fusion or advanced spina...

...ith advanced hip arthritis, we strongly recomm...

...th severe kyphosis, we conditionally recom...

...ns for Adults With AS-Related Comorbiditie...

...7. In adults with acute iritis, we str...

...8. In adults with recurrent iritis, w...

...s with recurrent iritis, we conditi...

...th inflammatory bowel disease, we do not recom...

...n adults with inflammatory bowel disease,...

...Assessment, Imaging, and Screening...

...tionally recommend the regular-interval us...

...ally recommend regular-interval use and monitoring...

...ts with active AS, we conditionally recommend agai...

...ditionally recommend screening for osteop...

...ith syndesmophytes or spinal fusion, we c...

...ongly recommend against screening for...

...strongly recommend against screening for v...

...9. In adults with AS of unclear activity while...

...ith stable AS, we conditionally recommend ag...

...In adults with active or stable AS on any tr...

...endations were from 2015 and were not rev...


...ations for the Treatment of Adults...

...ecommendations for Adults With Act...

...We strongly recommend treatment with NSAI...

...ally recommend continuous treatment with...

...recommend any particular NSAID as the pre...

...adults with active nonradiographic axial SpA d...

.... In adults with active nonradiographic...

...not recommend any particular TNFi as the preferred...

58. In adults with active nonradio...

59. In adults with active nonradiographic a...

...with active nonradiographic axial SpA de...

...with active nonradiographic axial SpA...

...adults with active nonradiographic axial...

...ts with active nonradiographic axial SpA and prima...

...lts with active nonradiographic axial S...

...th active nonradiographic axial SpA...

...s with active nonradiographic axial SpA despite t...

...recommend against treatment with systemic gl...

...n adults with isolated active sacroiliitis des...

...th active enthesitis despite treatment with NSA...

...with active peripheral arthritis despite treat...

...ngly recommend treatment with physical therapy...

.... We conditionally recommend active physical the...

...nally recommend land-based physical therapy inter...

...for Adults With Stable Nonradiogra...

...ally recommend on-demand treatment wit...

...s receiving treatment with TNFi and NSAIDs...

...lts receiving treatment with TNFi and a co...

...ceiving treatment with a biologic, we conditio...

...receiving treatment with a biologic, we condi...

.... In adults receiving treatment with a...

...ons for Adults With Active or Stable Nonradiogra...

...In adults receiving treatment with TNFi, we c...

...ase Activity Assessment and...

...ditionally recommend the regular-interval use and...

...e conditionally recommend regular-inte...

83. In adults with active nonradiographic axial S...

...In adults with nonradiographic axial Sp...

...lts with stable nonradiographic axial SpA, we...

86. In adults with active or stable nonradiog...

...mendations were from 2015 and were not reviewed in...


...1A. Treatment of Patients With Active AS...


...eatment of Patients With Stable AS...