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...
...Recommendations fo...
...We strongly recommend treatment with NSAIDs over...
...ally recommend continuous treatment with NSAIDs...
...not recommend any particular NSAID as th...
...adults with active AS despite treatment w...
...adults with active AS despite treatment with...
...h active AS despite treatment with...
.... We do not recommend any particular TNFi as...
...dults with active AS despite treatmen...
...ith active AS despite treatment with N...
...lts with active AS despite treatment with NSAIDs...
...n adults with active AS despite treatme...
...s with active AS despite treatment wit...
13. In adults with active AS despite treatmen...
...with active AS despite treatment with the firs...
...lts with active AS despite treatment w...
...e strongly recommend against treatment wi...
...ts with isolated active sacroiliitis de...
.... In adults with stable axial disease...
...with stable axial disease and active peripher...
...rongly recommend treatment with physic...
...conditionally recommend active physical therapy in...
...itionally recommend land-based physical therapy...
...Recom...
...We conditionally recommend on-demand tre...
...ts receiving treatment with TNFi an...
.... In adults receiving treatment with TNFi and a co...
...n adults receiving treatment with a b...
...s receiving treatment with a biologic, we condit...
...In adults receiving treatment with an origi...
...trongly recommend treatment with physical t...
...Recommendations fo...
...In adults receiving treatment with TNFi,...
...ally recommend advising unsupervised back exercise...
.... We conditionally recommend fall evaluatio...
...nditionally recommend participation in formal g...
34. In adults with spinal fusion or advanced s...
35. In adults with advanced hip arthritis,...
...ts with severe kyphosis, we conditionall...
...Recommenda...
...lts with acute iritis, we strongly recom...
...with recurrent iritis, we conditionally rec...
39. In adults with recurrent iritis, w...
...adults with inflammatory bowel disease, w...
.... In adults with inflammatory bowel diseas...
...Diseas...
...tionally recommend the regular-interv...
...itionally recommend regular-interval...
...ith active AS, we conditionally recommend...
...nally recommend screening for osteopenia/os...
...th syndesmophytes or spinal fusion,...
...trongly recommend against screening for...
...ongly recommend against screening for val...
...adults with AS of unclear activity while on a bio...
...lts with stable AS, we conditionally recommen...
...ults with active or stable AS on a...
...se recommendations were from 2015 an...
...Recommen...
...Reco...
...recommend treatment with NSAIDs over no treat...
...nally recommend continuous treatment wit...
...commend any particular NSAID as the prefe...
...5. In adults with active nonradiographic axial SpA...
...ith active nonradiographic axial SpA despite...
...not recommend any particular TNFi as...
...ts with active nonradiographic axial Sp...
...s with active nonradiographic axial...
...0. In adults with active nonradiographic axia...
...dults with active nonradiographic a...
...ith active nonradiographic axial SpA despite trea...
...with active nonradiographic axial SpA...
...n adults with active nonradiographic axi...
...th active nonradiographic axial SpA despite treat...
...adults with active nonradiographic axial SpA de...
...rongly recommend against treatment with...
...adults with isolated active sacroiliitis despit...
...In adults with active enthesitis despite treatme...
...lts with active peripheral arthritis despite...
...rongly recommend treatment with physical thera...
...We conditionally recommend active...
...e conditionally recommend land-based physical the...
...Recommendati...
...conditionally recommend on-demand treatment wit...
...In adults receiving treatment with TNFi and NSAID...
...ts receiving treatment with TNFi a...
...In adults receiving treatment with a bi...
...In adults receiving treatment with a biol...
...lts receiving treatment with an originator...
...Recommendations for Adu...
...In adults receiving treatment wit...
...Disease Activity Asse...
...nditionally recommend the regular-interval use...
...itionally recommend regular-interval use...
...s with active nonradiographic axial SpA, w...
...ts with nonradiographic axial SpA of unclear activ...
...ts with stable nonradiographic axial SpA, we condi...
...lts with active or stable nonradiograp...
...commendations were from 2015 and were not r...
...Treatment of Patients With Active AS...
...re 1B. Treatment of Patients With St...