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
...Treatme...
...Recommendatio...
...strongly recommend treatment with NSAIDs ov...
...conditionally recommend continuous...
...recommend any particular NSAID as the prefer...
...lts with active AS despite treatment...
...In adults with active AS despite tr...
...In adults with active AS despite treatment with N...
...do not recommend any particular TNFi as the prefe...
...In adults with active AS despite treatment with N...
...dults with active AS despite treatme...
...ts with active AS despite treatment with NSAIDs,...
11. In adults with active AS despit...
...ts with active AS despite treatment with th...
...ts with active AS despite treatment with the...
...ults with active AS despite treatment with th...
...ith active AS despite treatment with the first TN...
16. We strongly recommend against treatment...
...dults with isolated active sacroiliitis despite...
.... In adults with stable axial disease an...
...with stable axial disease and active peripheral...
.... We strongly recommend treatment with physi...
...ditionally recommend active physical...
...We conditionally recommend land-based...
...Rec...
...conditionally recommend on-demand treatment wi...
...dults receiving treatment with TNFi and NSAIDs, we...
...dults receiving treatment with TNFi and a conve...
...In adults receiving treatment with a bi...
.... In adults receiving treatment with a...
28. In adults receiving treatment with an origin...
...y recommend treatment with physical therapy ov...
...Recommendations...
.... In adults receiving treatment with TN...
.... We conditionally recommend advisi...
...ally recommend fall evaluation and counseling.a...
...conditionally recommend participation in...
...n adults with spinal fusion or advanced spinal os...
...with advanced hip arthritis, we strongly...
...n adults with severe kyphosis, we condition...
...Recom...
...s with acute iritis, we strongly rec...
.... In adults with recurrent iritis, w...
...dults with recurrent iritis, we condition...
...th inflammatory bowel disease, we do n...
...ults with inflammatory bowel disease, we...
Disease A...
.... We conditionally recommend the regular-inter...
...onditionally recommend regular-interval use...
...adults with active AS, we conditionally rec...
...ionally recommend screening for osteopen...
...6. In adults with syndesmophytes or spinal fus...
...y recommend against screening for cardiac con...
...y recommend against screening for valv...
...n adults with AS of unclear activity while on...
...dults with stable AS, we conditionally recomme...
...adults with active or stable AS on any tr...
...dations were from 2015 and were not...
...Recommendatio...
...Recommendati...
...We strongly recommend treatment with...
...ditionally recommend continuous treatment...
...do not recommend any particular NSAID as the pref...
55. In adults with active nonradiographic...
.... In adults with active nonradiograph...
...We do not recommend any particular T...
...ts with active nonradiographic axial SpA...
...In adults with active nonradiographic axia...
...lts with active nonradiographic axial SpA desp...
...with active nonradiographic axial SpA despite tr...
...ults with active nonradiographic axial SpA...
...adults with active nonradiographic...
...adults with active nonradiographic axial SpA and...
...dults with active nonradiographic axial SpA des...
...with active nonradiographic axial SpA...
...ly recommend against treatment with system...
...with isolated active sacroiliitis despite tr...
.... In adults with active enthesitis d...
...ts with active peripheral arthritis...
71. We strongly recommend treatment with...
...conditionally recommend active physical the...
...onally recommend land-based physical t...
...Recommendation...
...We conditionally recommend on-demand treatment...
...s receiving treatment with TNFi and N...
...ceiving treatment with TNFi and a conventional sy...
...In adults receiving treatment with a bio...
...eceiving treatment with a biologic, we con...
...ults receiving treatment with an originator...
...Recom...
...n adults receiving treatment with TNFi, we conditi...
...Disease Ac...
...conditionally recommend the regula...
...nditionally recommend regular-inte...
...ith active nonradiographic axial Sp...
...s with nonradiographic axial SpA of un...
...th stable nonradiographic axial SpA...
...adults with active or stable nonradi...
...ecommendations were from 2015 and were not r...
...tment of Patients With Active AS...
...atment of Patients With Stable A...