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

...eatment...

...for the Treatment of Adults With AS (Ta...

...ecommend treatment with NSAIDs over no tre...

...conditionally recommend continuous treatm...

...commend any particular NSAID as the preferred c...

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

...n adults with active AS despite treatment w...

...ults with active AS despite treatment...

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

...adults with active AS despite treatment wit...

...lts with active AS despite treatmen...

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

...s with active AS despite treatment with NSAI...

...lts with active AS despite treatment with...

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

...adults with active AS despite treatm...

...n adults with active AS despite treatment w...

...strongly recommend against treatment with s...

.... In adults with isolated active sacroiliitis...

...th stable axial disease and active enthesit...

...In adults with stable axial disease a...

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

...We conditionally recommend active physical ther...

...tionally recommend land-based physi...

...ations for Adults With Stable AS...

...itionally recommend on-demand treatme...

...receiving treatment with TNFi and NSAIDs, we c...

...eceiving treatment with TNFi and a conventional sy...

...In adults receiving treatment with...

27. In adults receiving treatment with a bio...

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

...We strongly recommend treatment w...

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

...s receiving treatment with TNFi, we conditionally...

...We conditionally recommend advising un...

...ditionally recommend fall evaluation and co...

...tionally recommend participation in formal group o...

...s with spinal fusion or advanced spinal osteoporo...

.... In adults with advanced hip arth...

...ults with severe kyphosis, we conditionall...

...dations for Adults With AS-Related Co...

...with acute iritis, we strongly recommend treatmen...

.... In adults with recurrent iritis, we c...

...dults with recurrent iritis, we conditi...

...0. In adults with inflammatory bowel disease,...

...dults with inflammatory bowel disease, we co...

...ivity Assessment, Imaging, and Screen...

42. We conditionally recommend the reg...

...We conditionally recommend regular-interval use...

...ts with active AS, we conditionally re...

...5. We conditionally recommend screening for...

...dults with syndesmophytes or spinal...

...trongly recommend against screening for ca...

...y recommend against screening for valv...

.... In adults with AS of unclear activ...

.... In adults with stable AS, we conditionally recom...

...th active or stable AS on any treatment, we cond...

a These recommendations were from...


...ommendations for the Treatment of Adults With N...

Recommendations for Adults With Active N...

...strongly recommend treatment with...

...conditionally recommend continuous tre...

54. We do not recommend any particular NSA...

...In adults with active nonradiographic axial SpA...

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

.... We do not recommend any particular TNFi as...

58. In adults with active nonradiographic...

...s with active nonradiographic axial SpA...

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

...ith active nonradiographic axial SpA desp...

...n adults with active nonradiographic ax...

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

...s with active nonradiographic axial SpA and...

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

...with active nonradiographic axial S...

...recommend against treatment with systemic...

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

...lts with active enthesitis despite treat...

...adults with active peripheral arthri...

...We strongly recommend treatment with physical t...

...conditionally recommend active physical therapy i...

...nally recommend land-based physical th...

...ndations for Adults With Stable Nonradi...

...nditionally recommend on-demand treatment w...

...receiving treatment with TNFi and NSA...

...s receiving treatment with TNFi and a...

...7. In adults receiving treatment with a biologi...

...receiving treatment with a biologic,...

...In adults receiving treatment with...

...ions for Adults With Active or Stable Nonradiograp...

...ults receiving treatment with TNFi, we condit...

...Activity Assessment and Imaging...

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

...tionally recommend regular-interva...

...th active nonradiographic axial SpA, we con...

...n adults with nonradiographic axial SpA o...

...ith stable nonradiographic axial SpA, we cond...

...with active or stable nonradiographic...

...ecommendations were from 2015 and were not rev...


...gure 1A. Treatment of Patients W...


...re 1B. Treatment of Patients With Stabl...