ACR Treatment of Adults with Axial Spondyloarthritis 2026 Guideline Update - Key Recommendations

Guideline Video

Guideline Resources

• Treatment of Adults with Axial Spondyloarthritis 
• American College of Rheumatology
• June 24, 2026 (Posted online)
• Guideline Spotlight
• Full-text

Video Transcription

Today we’ll be going over the American College of Rheumatology’s newest guideline update on Treatment of Adults with Axial Spondyloarthritis (axSpA).

This guideline is an update to the 2019 guideline for treatment of ankylosing spondylitis and axSpaA and provides evidence-based and expert guidance for the diagnosis and management of axSpA and associated extra-musculoskeletal manifestations in adults.

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 with Recommendations for Evaluating Adults with SUSPECTED axSpA

• The guideline conditionally recommends obtaining a dedicated anteriorposterior (AP) pelvis radiograph over a lumbar spine radiograph.
• The guideline conditionally recommends against obtaining dedicated sacroiliac joint (SIJ) x-ray over an AP pelvis x-ray.
• The guideline conditionally recommends obtaining AP pelvis as the initial imaging test over spinal or SIJ MRI, or SIJ low-dose CT.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends obtaining MRI SIJ without contrast.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends obtaining MRI SIJ without contrast over MRI lumbar spine to detect axSpA.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends obtaining SIJ MRI over SIJ low-dose CT.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends obtaining SIJ MRI over bone scan.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends obtaining SIJ low-dose CT.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends against obtaining PET scan over spinal or SIJ MR.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends ordering a specific MRI SIJ protocol over ordering a non-specific protocol to detect axSpA.
• In adults with non-diagnostic plain radiography undergoing MRI of the SIJ, the guideline conditionally recommends ordering studies without gadolinium.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends having standardized MRI reporting over non-standardized reporting.
• In adults with non-diagnostic plain radiography, the guideline conditionally recommends having MRI interpreted by an individual experienced in detecting axSpA over a professional without specific experience in detecting axSpA. 

Next, Recommendations for Adults with ACTIVE OR INACTIVE axSpA

• 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 routine measurement using a standardized disease activity measure. 
• 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 axSpA disease-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 adults with AxSpA and unclear activity while on a b/tsDMARD, the guideline conditionally recommends obtaining a spinal or SIJ MRI to assess activity.
• The guideline conditionally recommends group or individual self-management education.
• The guideline conditionally recommends counseling regarding achieving an optimal weight. 
• The guideline conditionally recommends counseling regarding maintaining an optimal weight. 
• The guideline conditionally recommends cardiovascular disease risk screening. 
• The guideline conditionally recommends against screening for cardiac conduction defects with electrocardiogram.
• The guideline conditionally recommends against screening for valvular heart disease with echocardiogram.
• The guideline conditionally recommends depression screening and management.
• The guideline conditionally recommends counseling regarding intense physical labor.
• The guideline conditionally recommends counseling for modifications related to driving.
• The guideline conditionally recommends counseling regarding the dangers of contact sports over no such counseling, whether the disease is active or inactive.
• The guideline conditionally recommends against microbiome targeted therapy.
• The guideline conditionally recommends against treatment with alternative medicine.
• The guideline conditionally recommends acupuncture and massage therapy.
• In adults with axSpA with pain, the guideline conditionally recommends against treatment with cannabinoids.
• The guideline strongly recommends education regarding symptoms of uveitis.
• In adults with axSpA without a known history of uveitis, the guideline strongly recommends screening for uveitis with a medical history.
• In adults with axSpA without symptoms suggestive of active uveitis, the guideline conditionally recommends against screening by ophthalmologic exam.
• In adults with axSpA and a history of recurrent uveitis, the guideline conditionally recommends prescription of topical glucocorticoids for prompt at-home use in the event of eye symptoms.
• In adults with axSpA and a history of recurrent uveitis, the guideline conditionally recommends use of certain biologics over other b/tsDMARDs.
• In adults who develop recurrent uveitis while on TNFi monoclonal, the guideline conditionally recommends continuing on TNFi and adding topicals/ csDMARDs over switching the TNFi to a non-TNFi biologic.
• In adults with axSpA without a known history of IBD, the guideline strongly recommends screening for IBD with a medical history.
• In adults 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 adults with axSpA without a known history of IBD but with clinical findings suggestive of active IBD, the guideline strongly recommends testing using fecal calprotectin.
• In adults with active axSpA and inactive IBD, the guideline conditionally recommends against use of continuous/scheduled NSAIDs.
• In adults with axSpA and IBD, the guideline conditionally recommends use of certain NSAIDs over other NSAIDs.
• In adults with axSpA and IBD, the guideline conditionally recommends use of certain b/tsDMARDs over other b/tsDMARDs.
• In adults with axSpA without a known history of psoriasis, the guideline conditionally recommends evaluation for psoriasis.
• In adults with axSpA and active psoriasis, the guideline conditionally recommends use of certain biologics or tsDMARDs over other b/tsDMARD.
• In adults who develop mild 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 .

Then the section on Management of axSpA Complicated by Nociplastic Pain

• The guideline conditionally recommends treatment with gabapentinoid agents.
• The guideline conditionally recommends treatment with SSRI/SNRI agents.
• The guideline conditionally recommends treatment with muscle relaxants.
• The guideline conditionally recommends treatment with cognitive behavioral therapy.
• The guideline strongly recommends against treatment with opioid analgesics.

Next the section on Pharmacologic Management of Active and Inactive axSpA

• The guideline conditionally recommends against favoring TNFi or IL17i as a preferred treatment; the medication classes are considered equal.
• The guideline conditionally recommends treatment with TNFi over JAKi.
• The guideline conditionally recommends treatment with IL17i over JAKi.
• In adults with axSpA on IV infusion of a biologic, the guideline conditionally recommends rapid infusion over traditional rate of infusion.
• The guideline strongly recommends against treatment with adrenocorticotropic hormone.

Moving on to the section on Physical Therapy and Related Approaches for the Management of axSpA

• The guideline strongly recommends physical therapy in adults with active axSpA.
• The guideline conditionally recommends active physical therapy interventions over passive physical therapy interventions.
• The guideline conditionally recommends unsupervised back exercises over no exercise.
• The guideline conditionally recommends recreational exercises over no recreational exercise.
• The guideline conditionally recommends stretching over nonspecific exercises.
• The guideline conditionally recommends aquatic exercises over weight-bearing exercises.
• The guideline conditionally recommends aquatic physical therapy interventions over land-based physical therapy interventions.
• The guideline conditionally recommends repeat physical therapy over a one-time course of therapy.
• The guideline conditionally recommends aerobic exercises over nonspecific exercises.
• The guideline conditionally recommends yoga over nonspecific exercises.
• The guideline conditionally recommends Tai Chi over nonspecific exercises.
• The guideline conditionally recommends TENS over no TENS.
• The guideline conditionally recommends against radiofrequency ablation over no radiofrequency ablation.
• The guideline conditionally recommends against traction.
• The guideline strongly recommends against spinal manipulation.

Then the section on Surgical and Perioperative Management of axSpA

• In adults with cervical spine disease who will receive surgery that requires general anesthesia, the guideline strongly recommends intubation counseling.
• In adults with advanced hip arthritis, the guideline conditionally recommends total hip arthroplasty.
• In adults with severe kyphosis, the guideline conditionally recommends elective spinal osteotomy.
• In adults who have undergone THA, the guideline conditionally recommends celecoxib to prevent heterotopic ossification.
• In adults who have undergone THA, the guideline conditionally recommends against local radiation to prevent heterotopic ossification.
• In adults who have undergone THA, the guideline conditionally recommends against local radiation over celecoxib to prevent heterotopic ossification.

Moving on to the section on Management of Bone Health in axSpA

• The guideline strongly recommends fall evaluation and counseling.
• The guideline conditionally recommends screening for low bone mass with DXA scanning.
• The guideline conditionally recommends screening for low bone mass with DXA scanning over screening with other modalities such as CT.
• The guideline conditionally recommends against yearly screening for low bone mass with DXA scanning over screening every other year or every five years.
• In adults with osteoporosis, the guideline conditionally recommends against routine measurement of bone turnover markers.
• In adults with syndesmophytes or spinal fusion, the guideline conditionally recommends screening for low bone mass with DXA scan of the spine as well as the hips over DXA scan solely of the hip or other non‐spine site.
• In adults with osteoporosis, the guideline conditionally recommends the addition of anabolic or antiresorptive therapies to b/tsDMARD over b/tsDMARD alone.
• In adults with osteoporosis who have failed or have a contraindication to antiresorptive agents, the guideline conditionally recommends anabolic therapy over continuing antiresorptive therapy.

On to the section on Imaging in axSpA

• In adults with active axSpA on any treatment, the guideline conditionally recommends against obtaining repeat spine radiographs at a scheduled interval.
• In adults with inactive axSpA on any treatment, the guideline conditionally recommends against obtaining repeat spine radiographs at a scheduled interval.
• The guideline conditionally recommends against obtaining repeat pelvis or lumbar radiographs at a scheduled interval.
• In adults with axSpA of unclear activity while on a b/tsDMARD, the guideline strongly recommends obtaining spinal or SIJ MRI to assess activity over PET scan.
• In adults with axSpA of unclear activity while on a b/tsDMARD, the guideline conditionally recommends obtaining spinal or SIJ MRI to assess activity over bone scan.

Next, Recommendations for Adults with ACTIVE axSpA

• The guideline conditionally recommends against a treat-to-target strategy over a symptom-prompted treatment strategy.
• The guideline conditionally recommends a goal of low disease activity over other targets.

Now the section on Pharmacologic Management of Active axSpA—First-Line Therapies

• The guideline strongly recommends use of NSAIDs.
• In adults with active axSpA despite NSAID monotherapy, the guideline strongly recommends against switching to combination NSAIDs over NSAID monotherapy. 
• The guideline conditionally recommends certain NSAIDs over other NSAIDs.
• The guideline conditionally recommends continuous NSAID treatment over on-demand NSAID treatment. 
• The guideline conditionally recommends use of NSAIDs as first-line therapy over b/tsDMARD.
• For adults at high risk of poor outcomes, the guideline conditionally recommends b/tsDMARDs as initial pharmacologic treatment over starting with NSAIDs as initial therapy.
• In adults with active axSpA despite NSAIDs, the guideline conditionally recommends switching to a new NSAID over continuing the original NSAID.
• The guideline conditionally recommends against use of systemic glucocorticoids. 
• In adults with axSpA and active sacroiliitis, the guideline conditionally recommends treatment with intra-articular glucocorticoids. 

Then the section on Pharmacologic Management of Active axSpA—Second-Line Therapies

• The guideline strongly recommends treatment with TNFi.
• The guideline strongly recommends treatment with IL-17i.
• The guideline strongly recommends treatment with JAKi.
• The guideline conditionally recommends against certain TNFi over other TNFi.
• The guideline conditionally recommends against certain IL-17i over other IL-17i.
• The guideline conditionally recommends against certain JAKi over other JAKi.
• The guideline conditionally recommends against treatment with csDMARD.
• The guideline strongly recommends against treatment with opioid analgesics over b/tsDMARDs.
• The guideline conditionally recommends against treatment with bisphosphonates.
• The guideline conditionally recommends against treatment with abatacept, rituximab, tocilizumab, sarilumab, belimumab, or anakinra.
• The guideline strongly recommends against treatment with IL-23i.
• In adults with axSpA and active peripheral arthritis, the guideline conditionally recommends intra-articular glucocorticoids.
• In adults with axSpA and active peripheral arthritis, the guideline conditionally recommends csDMARD/b/tsDMARDs.
• In adults with axSpA and active enthesitis, the guideline conditionally recommends peri-entheseal glucocorticoid injections.

Now onto the section on Pharmacologic Management of Active axSpA—Subsequent Therapies

• In adults with active axSpA despite treatment with the first b/tsDMARD used, the guideline conditionally recommends switching to a different b/tsDMARD from the same class over adding a csDMARD.
• In adults with active axSpA despite treatment with the first b/tsDMARD used, the guideline conditionally recommends against switching to a different agent from the same class over switching to different class of b/tsDMARD.
• In adults with active axSpA despite maximum FDA-approved dosing of bDMARD, the guideline conditionally recommends dosing above the FDA approved maximum dose.
• In adults with treatment "refractory" axSpA, the guideline conditionally recommends depression screening and management over no depression screening and management.
• In adults with active axSpA despite bDMARD/tsDMARD monotherapy, the guideline conditionally recommends against co-treatment/combination with csDMARD.
• In adults with active axSpA despite bDMARD/tsDMARD monotherapy, the guideline conditionally recommends the use of dual therapy over bDMARD/tsDMARD monotherapy.
• In adults 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.
• In adults 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.
• In adults with active axSpA despite bDMARD, the guideline conditionally recommends against management based on serum anti-drug antibody monitoring and/or serum medication concentrations.
• In adults 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 b/tsDMARD.
• In adults with axial PsA, the guideline conditionally recommends against treatment with IL-23i.

And last, Recommendations for Adults with INACTIVE axSpA

• In adults with asymptomatic axSpA at high risk of poor outcomes, the guideline conditionally recommends pharmacologic therapy over no pharmacologic therapy.
• The guideline conditionally recommends against continuous NSAID treatment over on-demand NSAID treatment.
• In adults on an originator bDMARD, the guideline conditionally recommends continuation of originator bDMARD over switching to its biosimilar bDMARD.
• In adults on treatment with a b/tsDMARD, the guideline strongly recommends against discontinuations/withdrawing without tapering.
• In adults with inactive axSpA on treatment with a b/tsDMARD, the guideline conditionally recommends reducing frequency or dose of the b/tsDMARD over maintaining the current frequency and dose.
• In adults on treatment with a b/tsDMARD and NSAIDs, the guideline conditionally recommends against continuing treatment of both over treating with the b/tsDMARD alone.
• In adults on treatment with a b/tsDMARD and a csDMARD, the guideline conditionally recommends discontinuing the csDMARD over continuing treatment with both therapies.
• In adults with clinically inactive axSpA, the guideline strongly recommends against obtaining a spinal or MRI SIJ to confirm inactivity.

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.

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