ASAS/EULAR recommendations for the management of ankylosing spondylitis

Jane Zochling ¹, Désirée van der Heijde ², Rubén Burgos-Vargas ³, Eduardo Collantes ⁴, John C. Davis, Jr. ⁵, Ben Dijkmans ⁶, Maxime Dougados ⁷, Pál Géher ⁸, Robert D Inman ⁹, Muhammad Asim Khan ¹⁰, Tore K Kvien ¹¹, Marjatta Leirisalo-Repo ¹², Ignazio Olivieri ¹³, Karel Pavelka ¹⁴, Joachim Sieper ¹⁵, Gerold Stucki ¹⁶, Roger D Sturrock ¹⁷, Sjef van der Linden ², Daniel Wendling ¹⁸, Heinrich Böhm ¹⁹, Barend J van Royen ⁶ and Jürgen Braun ^20*

¹ Rheumazentrum-Ruhrgebiet, Germany
² University Hospital Maastricht, Netherlands
³ Hospital General de México, Mexico
⁴ Facultad de Medicina, Spain
⁵ University of California San Francisco, United States
⁶ VU University Medical Centre, Netherlands
⁷ Hospital Cochin, France
⁸ Semmelweis University, Hungary
⁹ Toronto Western Hospital, Canada
¹⁰ Case Western Reserve University at MetroHealth Medical Center, United States
¹¹ Diakonhjemmet Hospital, Norway
¹² Helsinki University Central Hospital, Finland
¹³ S Carlo Hospital, Italy
¹⁴ Na slupi 4, Czech Republic
¹⁵ Charité, Campus Benjamin Franklin, Germany
¹⁶ University of Munich, Germany
¹⁷ Glasgow Royal Infirmary, United Kingdom
¹⁸ CHU J Minjoz, France
¹⁹ Zentralklinik Bad Berka, Germany
²⁰ Rheumazentrum Ruhrgebiet, Germany

^* To whom correspondence should be addressed. E-mail: j.braun{at}rheumazentrum-ruhrgebiet.de.

Accepted 22 August 2005

Abstract

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

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 (ES), relative risk (RR), number needed to treat (NNT) and incremental cost- effectiveness ratio (ICER) 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 addressed the use of NSAIDs (conventional NSAIDs, coxibs, and co- prescription of gastro-protective agents), disease- modifying anti-rheumatic drugs, biological therapies, simple analgesics, local and systemic steroids, non- pharmacological therapy (including education, exercise and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (category I to IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied dependent on 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. They will be updated regularly in order to keep abreast of new developments in the management of AS.

Keywords: ankylosing spondylitis, evidence-based medicine, management, recommendations

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