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
...atment...
...tions for the Treatment of Adults Wi...
...recommend treatment with NSAIDs over no...
...conditionally recommend continuous trea...
...recommend any particular NSAID as...
...adults with active AS despite treatmen...
...th active AS despite treatment with NSAIDs, we con...
...dults with active AS despite treatm...
...o not recommend any particular TNFi as...
...In adults with active AS despite trea...
...adults with active AS despite treatment...
.... In adults with active AS despite treatm...
...with active AS despite treatment wi...
...ts with active AS despite treatment with t...
...with active AS despite treatment w...
.... In adults with active AS despite tre...
15. In adults with active AS despite t...
...strongly recommend against treatment wit...
...In adults with isolated active sacroiliitis despi...
18. In adults with stable axial disea...
...In adults with stable axial disease and ac...
...0. We strongly recommend treatment...
...We conditionally recommend active physical th...
...ally recommend land-based physical therapy inter...
...tions for Adults With Stable AS...
...We conditionally recommend on-demand treatment...
.... In adults receiving treatment with TNFi and NS...
...ts receiving treatment with TNFi and a conventio...
...receiving treatment with a biologic,...
...eceiving treatment with a biologic, we c...
...ults receiving treatment with an origina...
...recommend treatment with physical t...
...ndations for Adults With Active or...
...0. In adults receiving treatment with TNFi, w...
...onally recommend advising unsupervised back exe...
...We conditionally recommend fall evaluation an...
...nditionally recommend participation in f...
.... In adults with spinal fusion or advanced...
...ith advanced hip arthritis, we strongly...
...with severe kyphosis, we conditionally r...
...ions for Adults With AS-Related Comorbidities...
...In adults with acute iritis, we str...
...In adults with recurrent iritis, we c...
...n adults with recurrent iritis, we conditio...
...In adults with inflammatory bowel d...
...adults with inflammatory bowel disease,...
Disease Activity Assessment, Imaging,...
42. We conditionally recommend the r...
...itionally recommend regular-interval use and...
...ts with active AS, we conditionally recomme...
...itionally recommend screening for osteo...
46. In adults with syndesmophytes or sp...
...We strongly recommend against screening for...
...e strongly recommend against screening fo...
...adults with AS of unclear activity whi...
...adults with stable AS, we conditio...
...ts with active or stable AS on any tr...
...ndations were from 2015 and were not reviewed...
...dations for the Treatment of Adults With N...
...ions for Adults With Active Nonradiograp...
...recommend treatment with NSAIDs over no...
...conditionally recommend continuous treatment wi...
...recommend any particular NSAID as th...
...with active nonradiographic axial SpA d...
...adults with active nonradiographic axial Sp...
...do not recommend any particular TNFi as the pre...
...ults with active nonradiographic axial SpA des...
...9. In adults with active nonradiograp...
60. In adults with active nonradiographic axi...
...ts with active nonradiographic axial SpA...
...adults with active nonradiographic axial S...
...th active nonradiographic axial SpA an...
...adults with active nonradiographic axial...
...In adults with active nonradiogra...
...th active nonradiographic axial SpA desp...
...ngly recommend against treatment with systemic glu...
...ts with isolated active sacroiliitis despite...
.... In adults with active enthesitis desp...
...In adults with active peripheral arthritis des...
...strongly recommend treatment with ph...
...conditionally recommend active physica...
...onditionally recommend land-based physical thera...
...ations for Adults With Stable Nonra...
74. We conditionally recommend on-demand tre...
...n adults receiving treatment with TNFi and N...
...ceiving treatment with TNFi and a convention...
77. In adults receiving treatment w...
...ults receiving treatment with a biologic, w...
...In adults receiving treatment with an orig...
...commendations for Adults With Active or...
...ceiving treatment with TNFi, we conditionall...
...Activity Assessment and Imaging...
...We conditionally recommend the regular-interva...
...ditionally recommend regular-interval us...
83. In adults with active nonradiograph...
...with nonradiographic axial SpA of uncle...
...In adults with stable nonradiographic axia...
86. In adults with active or stable nonradiog...
...These recommendations were from 201...
...1A. Treatment of Patients With Active AS...
...1B. Treatment of Patients With S...