Ankylosing Spondylitis
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
| 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
...reatment...
Recommendations for the Treatment o...
...e strongly recommend treatment with NSAIDs ove...
...onditionally recommend continuous treatment with...
...not recommend any particular NSAID as the preferre...
...In adults with active AS despite trea...
...with active AS despite treatment with NSAIDs, w...
...with active AS despite treatment with NS...
...not recommend any particular TNFi...
...ts with active AS despite treatment with...
...h active AS despite treatment with NSAIDs...
...ts with active AS despite treatment wit...
...th active AS despite treatment with NSAIDs and w...
...n adults with active AS despite treatment...
...lts with active AS despite treatment with t...
...ith active AS despite treatment with the first...
...ith active AS despite treatment with the first T...
...strongly recommend against treatment with sys...
17. In adults with isolated active sacroilii...
...ith stable axial disease and active en...
...adults with stable axial disease an...
...We strongly recommend treatment with physical the...
...1. We conditionally recommend active phys...
...nditionally recommend land-based physical therapy...
...ations for Adults With Stable AS...
...conditionally recommend on-demand trea...
...adults receiving treatment with TNFi and NSAIDs,...
...ts receiving treatment with TNFi and a...
...adults receiving treatment with a...
...ts receiving treatment with a biologi...
...s receiving treatment with an originator TNFi, we...
...ly recommend treatment with physical thera...
...for Adults With Active or Stable A...
...dults receiving treatment with TNFi,...
...ally recommend advising unsupervise...
...nally recommend fall evaluation and counseling.a (...
...ditionally recommend participation in...
...adults with spinal fusion or advanced sp...
...ults with advanced hip arthritis, we strongl...
...In adults with severe kyphosis, we c...
...for Adults With AS-Related Comorbi...
...with acute iritis, we strongly rec...
.... In adults with recurrent iritis, we cond...
...with recurrent iritis, we condition...
.... In adults with inflammatory bowel disease, we...
...ith inflammatory bowel disease, we conditionall...
...sease Activity Assessment, Imaging, and Screening...
...nditionally recommend the regular-interv...
...itionally recommend regular-interval u...
...ults with active AS, we conditionally r...
.... We conditionally recommend screenin...
...lts with syndesmophytes or spinal fusion, we c...
...strongly recommend against screening for ca...
.... We strongly recommend against screeni...
...ith AS of unclear activity while on a...
...ith stable AS, we conditionally recom...
...s with active or stable AS on any...
...mendations were from 2015 and were not re...
...for the Treatment of Adults With Nonra...
...ations for Adults With Active Nonrad...
...gly recommend treatment with NSAIDs over...
...conditionally recommend continuous treat...
...not recommend any particular NSAID as the...
.... In adults with active nonradiographic axial S...
...ults with active nonradiographic axial SpA d...
...do not recommend any particular TNFi as the p...
...with active nonradiographic axial...
59. In adults with active nonradiogr...
...ith active nonradiographic axial SpA despit...
...with active nonradiographic axial SpA despite tre...
...adults with active nonradiographic axial S...
...adults with active nonradiographic axial S...
64. In adults with active nonradiographic...
...ith active nonradiographic axial SpA...
...adults with active nonradiographic axial SpA d...
...ngly recommend against treatment w...
68. In adults with isolated active sacroiliitis...
69. In adults with active enthesiti...
...adults with active peripheral arthritis despite tr...
...We strongly recommend treatment with physi...
...ally recommend active physical therapy interventi...
...3. We conditionally recommend land-based physical...
...ns for Adults With Stable Nonradiographic Axial...
74. We conditionally recommend on-demand treatm...
...adults receiving treatment with TNFi and NSAI...
...s receiving treatment with TNFi and a conventiona...
...n adults receiving treatment with a biol...
...s receiving treatment with a biologic, we condit...
...adults receiving treatment with an origin...
...ns for Adults With Active or Stable Nonradio...
...receiving treatment with TNFi, we conditionally...
...Activity Assessment and Imaging...
...1. We conditionally recommend the regular-interv...
.... We conditionally recommend regular-interv...
...lts with active nonradiographic axial...
...adults with nonradiographic axial...
...n adults with stable nonradiograph...
...th active or stable nonradiographic axial SpA o...
...These recommendations were from 2015 and wer...
...ure 1A. Treatment of Patients With...
...1B. Treatment of Patients With Stable...