Treatment Guidelines Updated for Ankylosing Spondylitis, Axial SpA

In a special article published online in Arthritis Care & Research, the American College of Rheumatology, Spondylitis Association of America, and Spondyloarthritis Research and Treatment Network present updated recommendations for the treatment of ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).

Michael M. Ward, M.D., M.P.H., from the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda, Maryland, and colleagues conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in previous guidelines and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging.

The researchers note that for AS and nonradiographic axial SpA, the recommendations are similar. As the first biologic to be used, tumor necrosis factor inhibitors (TNFi) are recommended over secukinumab or ixekizumab. For patients with primary nonresponse to the first TNFi, either secukinumab or ixekizumab is recommended over a second TNFi. Secukinumab, ixekizumab, and TNFi are favored over tofacitinib. Low-dose methotrexate coadministered with TNFi is not recommended; in patients with stable disease, a strict treat-to-target strategy and discontinuation or tapering of biologics are not recommended. For persistent peripheral arthritis, sulfasalazine is recommended only when TNFi are contraindicated. Spine or pelvis magnetic resonance imaging could aid in the assessment of unclear disease activity. Serial spine radiographs are not recommended for routine monitoring of radiographic changes.

"These guidelines update those from four years ago by consolidating the expert thought around the use of the newest therapeutic agents and modifying a number of recommendations from the 2015 guideline to reflect recent evidence," a coauthor said in a statement.

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