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
Treatment
...s for the Treatment of Adults With AS (Table 2...
...y recommend treatment with NSAIDs over no t...
...nditionally recommend continuous treatment with...
...We do not recommend any particular...
.... In adults with active AS despite...
...with active AS despite treatment with NSAI...
...In adults with active AS despite tre...
7. We do not recommend any particular TNFi...
...ith active AS despite treatment with NSAIDs, we...
...dults with active AS despite treatment with NSAIDs...
...th active AS despite treatment with NSAIDs, we con...
11. In adults with active AS despite trea...
...In adults with active AS despite t...
...n adults with active AS despite treatment with the...
...In adults with active AS despite treatm...
...ults with active AS despite treatm...
16. We strongly recommend against treatment wit...
...lts with isolated active sacroilii...
...adults with stable axial disease and active ent...
...ults with stable axial disease and active p...
...e strongly recommend treatment with physica...
.... We conditionally recommend activ...
...ally recommend land-based physical therapy...
...ns for Adults With Stable AS...
...ionally recommend on-demand treatment with...
...eceiving treatment with TNFi and NSAIDs,...
...5. In adults receiving treatment with...
...receiving treatment with a biologic, we conditio...
...receiving treatment with a biologic, we condit...
...adults receiving treatment with an originator TNF...
...e strongly recommend treatment with ph...
Recommendations for Adults With Ac...
...ults receiving treatment with TNFi, we co...
...onally recommend advising unsuperv...
...We conditionally recommend fall evaluation and co...
...itionally recommend participation in...
.... In adults with spinal fusion or advanc...
...5. In adults with advanced hip arthritis, we str...
.... In adults with severe kyphosis, we conditio...
...ions for Adults With AS-Related Comorbiditi...
...dults with acute iritis, we strongly...
...adults with recurrent iritis, we conditionally re...
...9. In adults with recurrent iritis, we condi...
...In adults with inflammatory bowel disea...
...In adults with inflammatory bowel disease, we co...
...isease Activity Assessment, Imaging, a...
42. We conditionally recommend the regu...
...itionally recommend regular-interval...
...dults with active AS, we conditionally recommen...
...We conditionally recommend screening...
...adults with syndesmophytes or spinal fusion, we...
...strongly recommend against screening...
.... We strongly recommend against screening for v...
...In adults with AS of unclear activity while...
.... In adults with stable AS, we conditionally reco...
...adults with active or stable AS on a...
...mendations were from 2015 and were not revi...
...ommendations for the Treatment of Adul...
...ations for Adults With Active Nonradiographic...
...We strongly recommend treatment with NSAIDs over n...
...nditionally recommend continuous treatment...
...do not recommend any particular NSAID as the pre...
...lts with active nonradiographic axial Sp...
...ith active nonradiographic axial SpA despite trea...
...o not recommend any particular TNFi as the...
...adults with active nonradiographic axial SpA...
...In adults with active nonradiographic a...
...In adults with active nonradiographic axial SpA de...
61. In adults with active nonradiographic a...
...with active nonradiographic axial SpA desp...
63. In adults with active nonradiographic axial...
...lts with active nonradiographic axial SpA and...
...adults with active nonradiographic axial SpA...
...n adults with active nonradiographic axial Sp...
...strongly recommend against treatment wit...
...with isolated active sacroiliitis despi...
...lts with active enthesitis despite trea...
...s with active peripheral arthritis despite...
...e strongly recommend treatment wit...
...conditionally recommend active physical therapy i...
73. We conditionally recommend land-based physical...
...ations for Adults With Stable Nonradiographic A...
...We conditionally recommend on-demand tre...
...ceiving treatment with TNFi and NSAIDs,...
...adults receiving treatment with TNFi an...
...lts receiving treatment with a biologic...
...In adults receiving treatment with...
79. In adults receiving treatment with...
...s for Adults With Active or Stable Nonrad...
...adults receiving treatment with TN...
...sease Activity Assessment and Imagi...
...onditionally recommend the regular-int...
...We conditionally recommend regular-interval use...
.... In adults with active nonradiographi...
...with nonradiographic axial SpA of unclear acti...
...In adults with stable nonradiographic axial SpA...
...lts with active or stable nonradiograph...
a These recommendations were from 2015 a...
...igure 1A. Treatment of Patients With A...
...1B. Treatment of Patients With Stable AS...