The American College of Rheumatology (ACR) recently released a pair of guidelines focusing on diagnosing and treating axial spondyloarthritis (axSpA) in adults and adolescents/children. For today’s spotlight, we are focusing on the guideline for adolescents and children.

Released side by side with the axSpA treatment guideline for adults, Recommendations for Diagnosis and Treatment of Children and Adolescents with Axial Spondyloarthritis features 121 recommendations outlining diagnosis, education, counseling, monitoring, pharmacologic treatment, and more. View the full-text version of the ACR guideline for the complete look at the recommendations, their recommendation strength, and levels of evidence supporting each.

Key Recommendations from the 2026 ACR Guideline Diagnosis and Treatment of Children and Adolescents with Axial Spondyloarthritis (axSpA)

The following recommendations are all “strong” or “strong against” recommendations. 

Diagnosis:

  • We strongly recommend obtaining an MRI of the sacroiliac joints without contrast over not obtaining an MRI to detect axSpA.
  • We strongly recommend obtaining SIJ MRI over SIJ low-dose (low radiation) CT.
  • We strongly recommend obtaining MRI of the sacroiliac joints over bone scan.
  • We strongly recommend obtaining MRI of the sacroiliac joints without contrast over MRI of the lumbar spine to detect axSpA.

Monitoring:

  • In children and adolescents with axSpA and unclear activity while on a b/tsDMARD, we strongly  recommend obtaining a spinal or SIJ MRI to assess activity over not obtaining an MRI.
  • In children and adolescents with axSpA and unclear activity while on a b/tsDMARD, we strongly recommend obtaining MRI of the SIJ to assess activity over bone scan.
  • In children and adolescents with active axSpA on any treatment, we strongly recommend against obtaining repeat spine radiographs at a scheduled interval (e.g., every two years).
  • In children and adolescents with inactive axSpA on any treatment, we strongly recommend against obtaining repeat spine radiographs at a scheduled interval (e.g., every two years).
  • In children and adolescents with axSpA irrespective of disease activity, we strongly recommend against obtaining repeat pelvis radiographs at a scheduled interval (e.g., every two years).

Initial Pharmacologic Treatment of Active Juvenile axSpA:

  • In children and adolescents with active axSpA despite NSAID monotherapy, we strongly recommend against switching to combination NSAIDs over NSAID monotherapy.
  • We strongly recommend against treatment with adrenocorticotrophic hormone.
  • We strongly recommend treatment with TNFi.
  • We strongly recommend treatment with IL-17i.
  • We strongly recommend against treatment with opioid analgesics over b/tsDMARDs.
  • We strongly recommend against cannabinoids (THC and CBD) over no treatment with cannabinoids.

Evaluation and MAnagement of Disease Features Associated with Juvenile axSpA:

Peripheral Arthritis and Enthesitis:

  • In children and adolescents with axSpA and active peripheral arthritis, we strongly recommend b/cs/tsDMARDs over no use of b/cs/tsDMARDs.

Uveitis:

  • We strongly recommend education regarding signs/symptoms of uveitis.
  • In HLA-B27-negative children and adolescents with axSpA without symptoms of active uveitis, we strongly recommend screening by ophthalmic exam over no screening by ophthalmologic exam.

Inflammatory Bowel Disease:

  • In children and adolescents with axSpA without a known history of IBD, we strongly recommend screening for IBD over no screening.
  • In children and adolescents with axSpA and IBD (active or inactive), we strongly recommend use of JAKi and monoclonal antibodies against TNF over other b/tsbDMARDs.

Nociplastic Pain:

  • We strongly recommend against treatment with SSRI/SSNI agents over no treatment.
  • We strongly recommend against treatment with muscle relaxants over no treatment.
  • We strongly recommend against treatment with opioids over no treatment.

Non-Pharmaceutical Therapy:

  • We strongly recommend against spinal manipulation.

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