Key Points
- Ankylosing spondylitis (AS) is a form of chronic inflammatory arthritis characterized by sacroiliitis, enthesitis, and a marked propensity for sacroiliac joint and spinal fusion.
- Non-radiographic axial spondyloarthritis (nr-axSpA) encompasses patients with chronic back pain and features suggestive of spondyloarthritis but who do not meet classification criteria for AS.
- The goals of treatment of AS and nr-axSpA are to reduce symptoms, maintain spinal flexibility and normal posture, reduce functional limitations, maintain work ability, and decrease disease complications
Key Recommendations
- In adults with active AS, the ACR strongly recommends treatment with NSAIDs over no treatment with NSAIDs.
- In adults with active AS despite treatment with NSAIDs, the ACR strongly recommends treatment with TNFi compared to no treatment with TNFi.
- In adults with active AS, the ACR does not recommend any particular TNFi as the preferred choice, except for patients with concomitant inflammatory bowel disease or recurrent iritis.
- In adults with AS and inflammatory bowel disease, the ACR strongly recommends treatment with infliximab or adalimumab over treatment with etanercept.
- In adults with active AS, the ACR strongly recommends against treatment with systemic glucocorticoids.
- In adults with active AS, the ACR strongly recommends treatment with physical therapy over no treatment with physical therapy.
- In adults with AS and advanced hip arthritis, the ACR strongly recommends treatment with total hip arthroplasty over no surgery.
- In adults with active nonradiographic axial SpA despite treatment with NSAIDs, the ACR conditionally recommends treatment with TNFi compared to no treatment with TNFi.
Treatment
Table 1. Pharmacological Treatment of Adults with Active AS
| Evidence Qualitya | |
|---|---|
| The ACR strongly recommends treatment with NSAIDs over no treatment with NSAIDs. | Low |
| The ACR conditionally recommends continuous treatment with NSAIDs over on-demand treatment with NSAIDs. | Very Low |
| The ACR does not recommend any particular NSAID as the preferred choice. | Moderate-Low |
| The ACR strongly recommends against treatment with systemic glucocorticoids. | Very Low |
| Active AS despite treatment with NSAIDs | |
| The ACR conditionally recommends against treatment with slow-acting antirheumatic drugs (SAARDs) | Very Low-Moderate |
| The ACR strongly recommends treatment with TNFi compared to no treatment with TNFi. | Moderate |
| The ACR does not recommend any particular TNFi as the preferred choice, except for patients with concomitant inflammatory bowel disease or recurrent iritis. | Moderate |
| For patients who also have contraindications to TNFi, the ACR conditionally recommends treatment with a SAARD over treatment with a non-TNFi biologic. | Very Low-Low |
| Active AS despite treatment with the first TNFi used | |
| The ACR conditionally recommends treatment with a different TNFi over adding a SAARD. | Very Low |
| The ACR conditionally recommends treatment with a different TNFi over treatment with a non-TNFi biologic. | Very Low |
| Also with isolated active sacroiliitis despite treatment with NSAIDs | |
| The ACR conditionally recommends treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. | Very Low |
| Stable axial disease and active enthesitis despite treatment with NSAIDs | |
The ACR conditionally recommends using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. Note: Peri-tendon injections of achilles, patellar and quadriceps tendons should be avoided . | Very Low |
| Stable axial disease and active peripheral arthritis despite treatment with NSAIDs | |
| The ACR conditionally recommends using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. | Very Low |
aSee Table 10 for GRADE Scores of Quality of Evidence.
Table 2. Pharmacological Treatment of Adults with Stable AS
| Evidence Qualitya | |
|---|---|
| The ACR conditionally recommends on-demand treatment with NSAIDs over continuous treatment with NSAIDs. | Very Low |
| IF on treatment with TNFi and NSAIDs, the ACR conditionally recommends continuing treatment with TNFi alone compared to continuing both treatments. | Very Low |
| IF on treatment with TNFi and SAARDs, the ACR conditionally recommends continuing treatment with TNFi alone over continuing both treatments. | Very Low |
a See Table 10 for GRADE Scores of Quality of Evidence.
Table 3. Rehabilitation
| Active AS | Evidence Qualitya |
|---|---|
| The ACR strongly recommends treatment with physical therapy over no treatment with physical therapy. | Moderate |
| The ACR conditionally recommends active physical therapy interventions (supervised exercise) over passive physical therapy interventions (massage, ultrasound, heat). | Very Low |
| The ACR conditionally recommends land-based physical therapy interventions over aquatic therapy interventions. | Moderate |
| Stable AS | Evidence Qualitya |
| In adults with stable AS, the ACR strongly recommends treatment with physical therapy over no treatment with physical therapy. | Low |
| Either Active or Stable AS | Evidence Qualitya |
| The ACR conditionally recommends advising unsupervised back exercises. | Moderate |
| For patients who also have had spinal fusion or who have advanced spinal osteoporosis, the ACR strongly recommends against treatment with spinal manipulation. | Very Low |
a See Table 10 for GRADE Scores of Quality of Evidence.
Table 4. Monitoring
| Evidence Quality a | |
|---|---|
| The ACR conditionally recommends the regular interval use and monitoring of a validated AS disease activity measure. | Very Low |
| The ACR conditionally recommends regular interval use and monitoring of the C-reactive protein (CRP) concentrations or erythrocyte sedimentation rate (ESR) over usual care without regular CRP or ESR monitoring. | Very Low |
a See Table 10 for GRADE Scores of Quality of Evidence.
Table 5. Specific Impairments or Comorbidities
| Evidence Quality a | |
|---|---|
| Advanced hip arthritis | |
| The ACR strongly recommends treatment with total hip arthroplasty over no surgery. | Very Low |
| Severe kyphosis | |
| The ACR conditionally recommends against elective spinal osteotomy. | Very Low |
| Acute iritis | |
| The ACR strongly recommends treatment by an ophthalmologist to decrease the severity, duration, or complications of episodes. | Very Low |
| Recurrent iritis | |
| The ACR conditionally recommends prescription over no prescription of topical glucocorticoids for prompt at-home use in the event of eye symptoms to decrease the severity or duration of iritis episodes. The ACR conditionally recommends treatment with infliximab or adalimumab over treatment with etanercept to decrease recurrences of iritis. |
|
| Inflammatory bowel disease | |
| The ACR does not recommend any particular NSAID as the preferred choice to decrease the risk of worsening of inflammatory bowel disease symptoms. The ACR strongly recommends using treatment with TNFi monoclonal antibodies over treatment with etanercept. |
|
a See Table 10 for GRADE Scores of Quality of Evidence.
Table 6. Education and Preventive Care
| Evidence Quality a | |
|---|---|
| The ACR conditionally recommends participation in formal group or individual self-management education. | Moderate |
| The ACR conditionally recommends fall evaluation and counseling. | Very Low |
| The ACR conditionally recommends screening for osteopenia/osteoporosis with DXA scanning over no screening. | Very Low |
| The ACR strongly recommends against screening for cardiac conduction defects with electrocardiograms. | Very Low |
| The ACR strongly recommends against screening for valvular heart disease with echocardiograms. | Very Low |
| With syndesmophytes or spinal fusion | |
| The ACR conditionally recommends screening for osteoporosis/osteopenia with DXA scanning of the spine as well as the hips, compared to DXA scanning solely of the hip or other non-spine sites. | Very Low |
a See Table 10 for GRADE Scores of Quality of Evidence.
Table 7. Pharmacological Treatment of Active Non-radiographic Axial SpA
| Evidence Quality a | |
|---|---|
| In adults with active non-radiographic axial SpA despite treatment with NSAIDs | |
| The ACR conditionally recommends treatment with tumor necrosis factor inhibitors (TNFi) compared to no treatment with TNFi. | Moderate |
a See Table 10 for GRADE Scores of Quality of Evidence.
Figure 1. Management of Active AS
Figure 2. Management of Stable AS
Figure 3. Management of Stable AS
Table 8. SAARDs and Biologicals
| Slow-acting antirheumatic drugs (SAARDs) | |
|---|---|
| Apremilast | Otezla® |
| Azathioprine | generic |
| Leflunomide | Arava® |
| Methotrexate | generic |
| Sulfasalazine | generic |
| Thalidomide | Thalomid® |
| Tofacitinib | Xeljanz® |
| Tumor necrosis factor inhibitors (TNFi) | |
| Adalimumab | Humira® |
| Certolizumab | Cimzia® |
| Etanercept | Enbrel® |
| Golimumab | Simponi® |
| Infliximab | Remicade® |
| Biologicals other than tumor necrosis factor inhibitors | |
| Abatacept | Orencia® |
| Anakinra | Kineret® |
| Rituximab | Rituxan® |
| Tocilizumab | Actemra® |
| Ustekinumab | Stelara® |
Table 10. GRADE Scores of Quality of Evidencea
| Underlying methodology | Quality Rating |
|---|---|
| Randomized trials; or double-upgraded observational studies. | High |
| Downgraded randomized trials; or upgraded observational studies. | Moderate |
| Double-downgraded randomized trials; or observational studies. | Low |
| Triple-downgraded randomized trials; or downgraded observational studies; or case series/case reports. | Very Low |
Table 9. Outcomes Framework
Ankylosing Spondylitis Disease Activity Score
| 1. Mortality |
|---|
| 2. Health status |
|
|
|
| 3. Functional status |
|
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| 4. Serious adverse events |
| 5. AS-related morbidities |
a basdai.com
b http://www.rand.org/health/surveys_tools/mos/mos_core_36item.html
c http://www.asas-group.org/clinical-instruments.php?id=01
d https://www.carearthritis.com/tools/tools_html.anonlaunch?toolid=15&refid=/physicians.php
e basdai.com/BASFI.php
f http://www.arthritisdoctor.ca/basmi.php