EXTENDED REPORT

ASAS/EULAR recommendations for the management of ankylosing spondylitis

J Zochling¹, D van der Heijde², R Burgos-Vargas³, E Collantes⁴, J C Davis, Jr⁵, B Dijkmans⁶, M Dougados⁷, P Géher⁸, R D Inman⁹, M A Khan¹⁰, T K Kvien¹¹, M Leirisalo-Repo¹², I Olivieri¹³, K Pavelka¹⁴, J Sieper¹⁵, G Stucki¹⁶, R D Sturrock¹⁷, S van der Linden², D Wendling¹⁸, H Böhm¹⁹, B J van Royen²⁰ and J Braun²¹

¹ Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Herne, Germany, and Institute of Bone and Joint Research, Royal North Shore Hospital, Sydney, Australia
² Department of Internal Medicine, Division of Rheumatology, University Hospital Maastrict and Caphri Research Institute, The Netherlands
³ Department of Rheumatology, Hospital General de Mexico, Mexico
⁴ Servicio de Reumatologia, Hospital Reina Sofia, Cordoba, Spain
⁵ Division of Rheumatology, University of California San Francisco, San Francisco, USA
⁶ Department of Rheumatology, VU University Medical Centre, Amsterdam, The Netherlands
⁷ Service de Rheumatologie B, Hospital Cochin, Paris, France
⁸ Department of Rheumatology and Physiotherapy, Semmelweis University, Budapest, Hungary
⁹ Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
¹⁰ Case Western Reserve University, University, MetroHealth Medical Center, Division of Rheumatology, Cleveland, Ohio, USA
¹¹ Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
¹² Department of Medicine, Division of Rheumatology, Helsinki University Central Hospital, Helsinki, Finland
¹³ Rheumatology Department of Lucania, S Carlo Hospital, Potenza and Madonna delle Grazie Hospital, Matera, Italy
¹⁴ Institute of Rheumatology, Prague, Czech Republic
¹⁵ Department of Gastroenterology and Rheumatology, Charitè, Campus Benjamin Franklin, Berlin, Germany
¹⁶ Department of Physical Medicine and Rehabilitation, Ludwig-Maximilians-University, Munich, Germany
¹⁷ Centre for Rheumatic Diseases, University Department of Medicine, Glasgow Royal Infirmary, Glasgow, UK
¹⁸ Service de Rhumatologie, CHU Jean Minjoz, Besancon, France
¹⁹ Department for Orthopaedics, Spinal Surgery and Paraplegiology, Zentralklinik Bad Berka, Bad Berka, Germany
²⁰ Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, The Netherlands
²¹ Bochum University, Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Herne, Germany

Correspondence to:
Correspondence to:
Professor J Braun
Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Landgrafenstr 15, 44652 Herne, Germany; J.Braun{at}rheumazentrum-ruhrgebiet.de

Objective: To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the ‘ASsessment in AS’ international working group and the European League Against Rheumatism.

Methods: Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise.

Results: The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I–IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion.

Conclusion: Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.

Abbreviations: AS, ankylosing spondylitis; ASAS, ASsessment in AS; CI, confidence interval; DMARDs, disease modifying antirheumatic drugs; ES, effect size; MRI, magnetic resonance imaging; NRS, numerical rating scale; NSAIDs, non-steroidal anti-inflammatory drugs; OA, osteoarthritis; RCT, randomised controlled trial; THA, total hip arthroplasty; TNF, tumour necrosis factor; VAS, visual analogue scale

Keywords: ankylosing spondylitis; management; recommendations; evidence based medicine; spondyloarthropathies; ASAS; EULAR

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