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

Released side by side with the axial spondyloarthritis treatment guideline for adolescents and children, Recommendations for the Treatment of Adults with Axial Spondyloarthritis (axSpA) features 138 recommendations outlining evaluation, general approaches to management, pharmacologic management of axSpA,, and more. View the full-text version of the ACR guideline for the complete look at the recommendations, their strength, and level of evidence supporting each.

Key Recommendations from the 2026 ACR Guideline Treatment of Adults with Axial Spondyloarthritis (axSpA)

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

General Approaches to axSpA Management

Management of Uveitis, IBD, and Psoriasis in the Setting of axSpA:

  • We strongly recommend education regarding symptoms of uveitis.
  • In adults with axSpA without a known history of uveitis, we strongly recommend screening for uveitis with a medical history.
  • In adults with axSpA without a known history of IBD, we strongly recommend screening for IBD with a medical history.
  • In adults with axSpA without a known history of IBD but with clinical findings suggestive of active IBD, we strongly recommend testing using fecal calprotectin.

Management of axSpA Complicated by Nociplastic Pain

  • We strongly recommend against treatment with opioid analgesics.

Pharmacologic Management of Active and Inactive axSpA

  • We strongly recommend against treatment with adrenocorticotropic hormone.

Physical Therapy and Related Approaches for the Management of axSpA

  • We strongly recommend physical therapy in adults with active axSpA.
  • We strongly recommend against spinal manipulation.

Surgical and Perioperative Management of axSpA

  • In adults with cervical spine disease who will receive surgery that requires general anesthesia, we strongly recommend intubation counseling (advising anesthesiologist, informed consent of patient).

Management of Bone Health in axSpA

  • We strongly recommend fall evaluation and counseling.

Imaging in axSpA

  • In adults with axSpA of unclear activity while on a b/tsDMARD, we strongly recommend obtaining spinal or SIJ MRI to assess activity over PET scan.

Pharmacologic Management of Active axSpA-First-Line Therapies

  • We strongly recommend use of NSAIDs.
  • In adults with active axSpA despite NSAID monotherapy, we strongly recommend against switching to combination NSAIDs over NSAID monotherapy.

Pharmacologic Management of Active axSpA-Second-Line Therapies

  • We strongly recommend treatment with TNFi.
  • We strongly recommend treatment with IL-17i.
  • We strongly recommend treatment with JAKi (TOFA, UPA).
  • We strongly recommend against treatment with opioid analgesics over b/tsDMARDs.
  • We strongly recommend against treatment with IL-23i.

Recommendations for Adults with INACTIVE axSpA

  • In adults on treatment with a b/tsDMARD, we strongly recommend against discontinuations/withdrawing without tapering.
  • In adults with clinically inactive axSpA, we strongly recommend against obtaining a spinal or MRI SIJ to confirm inactivity.

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