ACR Diagnosis and Treatment of Children and Adolescents with Axial Spondyloarthritis 2026 Guideline

Published: July 28, 2026

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Diagnosis and Treatment of Children and Adolescents with Axial Spondyloarthritis
American College of Rheumatology
June 24, 2026 (Posted online)
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Today we’ll be going over the American College of Rheumatology’s newest guideline update on Diagnosis and Treatment of Children and Adolescents with Axial Spondyloarthritis (axSpA).

This guideline outlines specific recommendations for management of children and adolescents with juvenile axSpA and provides evidence-based and expert guidance for the diagnosis and management of axSpA and associated extra-musculoskeletal manifestations in children and adolescents.

In today’s rapid update, we’ll just be going over the key recommendations so for the full guideline, make sure to check it out on guidelinecentral.com

Let’s get started.

Starting on the section on Diagnosis in Children and Adolescents with Suspected axSpA

The guideline strongly recommends obtaining an MRI of the sacroiliac joints without contrast over not obtaining an MRI to detect axSpA.
The guideline conditionally recommends MRI of the sacroiliac joints over x-ray of the sacroiliac joints for diagnosis of juvenile axSpA.
The guideline strongly recommends obtaining SIJ MRI over SIJ low-dose CT.
The guideline strongly recommends obtaining MRI of the sacroiliac joints over bone scan.
The guideline strongly recommends obtaining MRI of the sacroiliac joints without contrast over MRI of the lumbar spine to detect axSpA.
The guideline conditionally recommends use of a specific MRI protocol over a non-specific protocol to detect axSpA.
The guideline conditionally recommends standardized MRI reporting over non-standardized reporting.
The guideline conditionally recommends having MRI interpreted by an individual experienced in detecting axSpA over a professional without specific experience in detecting axSpA.
The guideline conditionally recommends against use of gadolinium.
In children or adolescents with suspected axSpA undergoing plain radiography, the guideline conditionally recommends obtaining dedicated AP pelvis radiograph over a lumbar spine radiograph.
In children or adolescents with suspected axSpA undergoing plain radiography, the guideline conditionally recommends a simple AP pelvis radiograph over a dedicated SIJ radiograph.
In children and adolescents with enthesitis-related arthritis without axial symptoms, the guideline conditionally recommends obtaining MRI of the sacroiliac joints to detect axSpA.

Next the section on Education and Counseling

The guideline conditionally recommends group or individual self-management education.
The guideline conditionally recommends counseling regarding intense physical labor.
The guideline conditionally recommends counseling regarding contact sports.
The guideline conditionally recommends counseling regarding axSpA risk in first-degree relatives.
The guideline conditionally recommends against counseling to test first-degree relatives with genetic tests.
The guideline conditionally recommends counseling regarding achieving or maintaining an optimal weight.

Now the section on Monitoring

The guideline conditionally recommends measuring specific disease activity outcomes for axSpA over non-disease-specific measures.
The guideline conditionally recommends regular interval use and monitoring with the axSpA disease-specific measure over other non-disease-specific measures.
The guideline conditionally recommends regular interval use and monitoring with JIA-specific measure over other non-disease-specific measures.
The guideline conditionally recommends regular interval use and monitoring of C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) over usual care without CRP or ESR monitoring.
In children and adolescents with active axSpA despite bDMARD, the guideline conditionally recommends against management based on serum anti-drug antibody monitoring and/or serum medication concentrations.
The guideline conditionally recommends a goal of low disease activity.
In children and adolescents with axSpA and unclear activity while on a b/tsDMARD, the guideline strongly recommends 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, the guideline strongly recommends obtaining MRI of the SIJ to assess activity over bone scan.
In children and adolescents with clinically inactive axSpA, the guideline conditionally recommends against obtaining an MRI of the SIJ or spine to confirm inactivity.
In children and adolescents with active axSpA on any treatment, the guideline strongly recommends against obtaining repeat spine radiographs at a scheduled interval.
In children and adolescents with inactive axSpA on any treatment, the guideline strongly recommends against obtaining repeat spine radiographs at a scheduled interval.
In children and adolescents with axSpA irrespective of disease activity, the guideline strongly recommends against obtaining repeat pelvis radiographs at a scheduled interval.

Moving on to the section on Initial Pharmacologic Treatment of Active Juvenile axSpA

The guideline conditionally recommends treatment with NSAIDs over no treatment with NSAIDs.
The guideline conditionally recommends treatment with NSAIDs over b/tsDMARDs as first-line therapy.
In children and adolescents with active axSpA at risk of poor outcomes, the guideline conditionally recommends b/tsDMARDs as initial pharmacologic treatment over starting NSAIDs as initial therapy.
The guideline conditionally recommends COX-2 selective NSAIDs over non-selective NSAIDs.
The guideline conditionally recommends continuous NSAID treatment over on-demand NSAID treatment.
In children and adolescents with active axSpA despite NSAIDs, the guideline conditionally recommends switching to a new NSAID over continuing the original NSAID.
In children and adolescents with active axSpA despite NSAID monotherapy, the guideline strongly recommends against switching to combination NSAIDs over NSAID monotherapy.
The guideline conditionally recommends treatment with intra-articular glucocorticoids over no use of intra-articular glucocorticoids.
The guideline conditionally recommends against the use of systemic glucocorticoids.
The guideline strongly recommends against treatment with adrenocorticotrophic hormone.
The guideline conditionally recommends against treatment with csDMARD.
The guideline strongly recommends treatment with TNFi.
The guideline strongly recommends treatment with IL-17i.
The guideline conditionally recommends treatment with JAKi.
The guideline conditionally recommends against favoring TNFi or IL-17i as a preferred initial bDMARD treatment.
The guideline conditionally recommends against favoring any certain TNFi as the preferred choice over other TNFi.
The guideline conditionally recommends against favoring any certain IL-17i as the preferred choice over other IL-17i.
The guideline conditionally recommends against favoring any certain JAKi as the preferred choice over other JAKi.
The guideline conditionally recommends TNFi over JAKi.
The guideline conditionally recommends IL-17i over JAKi.
The guideline conditionally recommends against treatment with abatacept, rituximab, belimumab, tocilizumab, sarulimab, or IL-1 inhibition.
The guideline conditionally recommends against treatment with IL-23i.
The guideline conditionally recommends against treatment with bisphosphonates.
In children and adolescents with axSpA receiving IV biologic therapy, the guideline conditionally recommends a rapid infusion over a traditional infusion rate for ongoing infusions.
The guideline strongly recommends against treatment with opioid analgesics over b/tsDMARDs.
The guideline strongly recommends against cannabinoids over no treatment with cannabinoids.

Then the section on Ongoing Symptoms Despite Initial Pharmacologic Therapy

In children and adolescents with active axSpA despite treatment with the first b/tsDMARD used, the guideline conditionally recommends switching to a different class of b/tsDMARD over switching to a different agent from the same class.
In children and adolescents with active axSpA despite b/tsDMARD monotherapy, the guideline conditionally recommends against co-treatment/ combination with csDMARD.
In children and adolescents with active axSpA despite treatment with the first b/tsDMARD used, the guideline conditionally recommends switching to a different b/tsDMARD over adding a csDMARD.
In children and adolescents with active axSpA despite maximum FDA-approved dosing of bDMARD, the guideline conditionally recommends dosing above the FDA approved maximum dose over continuing on the FDA-approved maximum dose.
In children and adolescents with active axSpA without a response to two or more therapeutic agents from different classes, the rheumatologist should re-evaluate the reason for non-response prior to a trial of another b/tsDMARD.
In children and adolescents with active axSpA despite bDMARD/ tsDMARD monotherapy, the guideline conditionally recommends the use of dual therapy over bDMARD/ tsDMARD monotherapy.
The guideline conditionally recommends depression screening and management over no depression screening and management.
In children and adolescents with treatment “refractory” axSpA, the guideline conditionally recommends depression screening and management over no depression screening and management.

On to the section on Evaluation and Management of Disease Features Associated with Juvenile axSpA

In children and adolescents with axSpA and active peripheral arthritis, the guideline strongly recommends b/cs/tsDMARDs over no use of b/cs/tsDMARDs.
In children and adolescents with axSpA and active peripheral arthritis, the guideline conditionally recommends intra-articular glucocorticoids over no use of local glucocorticoid.
In children and adolescents with axSpA and active enthesitis, the guideline conditionally recommends against peri-entheseal glucocorticoid injections.
In children and adolescents with axSpA and peripheral arthritis, the guideline conditionally recommends topical NSAIDs as adjunctive therapy over no use of topical NSAIDs.
In children and adolescents with axSpA and enthesitis, the guideline conditionally recommends topical NSAIDs as adjunctive therapy over no use of topical NSAIDs.
Children and adolescents with axSpA and uveitis should be co-managed with an ophthalmologist.
The guideline strongly recommends education regarding signs/symptoms of uveitis.
In HLA-B27-negative children and adolescents with axSpA without symptoms of active uveitis, the guideline strongly recommends screening by ophthalmic exam over no screening by ophthalmologic exam.
In HLA-B27-positive children and adolescents with axSpA without symptoms of active uveitis, the guideline conditionally recommends screening by ophthalmic exam over no screening by ophthalmic exam.
In children and adolescents with axSpA and a history of recurrent uveitis, the guideline conditionally recommends prescription of topical glucocorticoid for prompt at-home use in the event of eye symptoms over no at-home use.
In children and adolescents with axSpA and a history of recurrent uveitis or complications from acute anterior uveitis, the guideline conditionally recommends treatment with csDMARDs/tsDMARDs/bDMARD/ glucocorticoids over no treatment.
In children and adolescents with axSpA and a history of recurrent or chronic uveitis, the guideline conditionally recommends TNFi monoclonal antibodies over other b/tsDMARDs .
In children and adolescents with axSpA who develop recurrent or chronic uveitis while on TNFi monoclonal antibodies, the guideline conditionally recommends continuing on TNFi and adding topicals/csDMARDs over switching the TNFi to a non-TNFi biologic.
Children and adolescents with active axSpA and psoriasis should be co-managed with a dermatologist.
In children and adolescents with axSpA without a known history of psoriasis, the guideline conditionally recommends screening for psoriasis.
In children and adolescents with axSpA and active psoriasis, the guideline conditionally recommends use of IL-17i over other b/tsDMARDs.
In children and adolescents with axSpA and psoriasis, the guideline conditionally recommends against treatment with IL-23i.
In children and adolescents with axSpA who develop TNFi-induced psoriasis, the guideline conditionally recommends continuing on TNFi and adding topicals/csDMARDs/phototherapy over switching the TNFi to a non-TNFi biologic or a different TNFi.
In children and adolescents with axSpA and psoriasis in which either condition is active despite bDMARD or tsDMARD monotherapy, the guideline conditionally recommends use of dual therapy over use of monotherapy.
Children and adolescents with active axSpA and IBD should be co-managed with a gastroenterologist.
In children and adolescents with axSpA without a known history of IBD, the guideline strongly recommends screening for IBD over no screening.
In children and adolescents with axSpA without a known history of IBD and without clinical findings suggestive of active IBD, the guideline conditionally recommends against screening using fecal calprotectin.
In children and adolescents with axSpA without a known history of IBD but with clinical findings suggestive of active IBD, the guideline conditionally recommends screening using fecal calprotectin.
In children and adolescents with active axSpA and inactive IBD, the guideline conditionally recommends against use of continuous/scheduled NSAIDs over no use of NSAIDs.
In children and adolescents with active axSpA and IBD, the guideline conditionally recommends COX-II selective NSAIDs over non-selective NSAIDs.
In children and adolescents with axSpA and IBD, the guideline strongly recommends use of JAKi and monoclonal antibodies against TNF over other b/tsbDMARDs.
In children and adolescents with axSpA and IBD in which either condition is active despite bDMARD or tsDMARD monotherapy, the guideline conditionally recommends use of dual therapy over use of monotherapy.
The guideline conditionally recommends against treatment with gabapentinoids over no treatment.
The guideline strongly recommends against treatment with SSRI/SSNI agents over no treatment.
The guideline strongly recommends against treatment with muscle relaxants over no treatment.
The guideline strongly recommends against treatment with opioids over no treatment.
The guideline conditionally recommends treatment with cognitive behavioral therapy over no treatment.
The guideline conditionally recommends counseling regarding sleep hygiene over no counseling.
The guideline conditionally recommends physical therapy over no treatment with physical therapy.

Then the section on Non-Pharmaceutical Therapy

In children and adolescents with active axSpA, the guideline conditionally recommends physical therapy.
In children and adolescents with inactive axSpA, the guideline conditionally recommends physical therapy over no treatment with PT.
The guideline conditionally recommends repeat PT over a one-time course of therapy.
In children and adolescents with active axSpA, the guideline conditionally recommends active PT interventions over passive PT interventions.
In children and adolescents with active axSpA, the guideline conditionally recommends aquatic PT interventions over land-based PT interventions.
The guideline conditionally recommends aquatic exercises over weight-bearing exercises.
The guideline conditionally recommends unsupervised back exercises over no exercise.
The guideline conditionally recommends recreational exercises over no recreational exercise.
The guideline conditionally recommends aerobic exercises over non-specific exercises.
The guideline conditionally recommends stretching over non-specific exercises.
The guideline conditionally recommends yoga over non-specific exercises.
The guideline conditionally recommends TENS over no TENS.
The guideline strongly recommends against spinal manipulation.
The guideline conditionally recommends against microbiome-targeted therapy.
The guideline conditionally recommends complementary/integrative medicine modalities such as acupuncture and massage therapy over no treatment by these modalities.
The guideline conditionally recommends against naturopathic, homeopathic, and ayurvedic medicine.

And last the section on Inactive Juvenile axSpA

In children and adolescents with inactive axSpA on an originator bDMARD, the guideline conditionally recommends continuation of originator bDMARD over switching to a biosimilar bDMARD.
In children and adolescents with inactive axSpA on treatment with a b/tsDMARD and NSAIDs, the guideline conditionally recommends continuation of the b/tsDMARD alone over treatment with both therapies.
In children and adolescents with inactive axSpA on treatment with a b/tsDMARD and NSAIDs, the guideline conditionally recommends on-demand NSAID treatment over continuous NSAID treatment.
In children and adolescents with inactive axSpA on a treatment with a b/tsDMARD and a csDMARD, the guideline conditionally recommends discontinuation of the csDMARD.
In children and adolescents with inactive axSpA on treatment with a b/tsDMARD, the guideline conditionally recommends against abrupt discontinuation of the ts/bDMARD.
In children and adolescents with inactive axSpA on a b/tsDMARD, the guideline conditionally recommends reducing frequency or dose of the b/tsDMARD over maintaining the current frequency and dose.
In children and adolescents with active axSpA because of withdrawal or discontinuation of b/tsDMARDs, the guideline conditionally recommends restarting the same agent over switching to a different agent from the same class or switching to a different agent from a different class of ts/bDMARD.

And there you have it. Make sure to check out the full guideline from the American College of Rheumatology and other related clinical decision support tools at guidelinecentral.com.

ACR Diagnosis and Treatment of Children and Adolescents with Axial Spondyloarthritis 2026 Guideline

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