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ASAS/EULAR recommendations for the management of ankylosing spondylitis
  1. J Zochling1,
  2. D van der Heijde2,
  3. R Burgos-Vargas3,
  4. E Collantes4,
  5. J C Davis Jr5,
  6. B Dijkmans6,
  7. M Dougados7,
  8. P Géher8,
  9. R D Inman9,
  10. M A Khan10,
  11. T K Kvien11,
  12. M Leirisalo-Repo12,
  13. I Olivieri13,
  14. K Pavelka14,
  15. J Sieper15,
  16. G Stucki16,
  17. R D Sturrock17,
  18. S van der Linden2,
  19. D Wendling18,
  20. H Böhm19,
  21. B J van Royen20,
  22. J Braun21
  1. 1Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Herne, Germany, and Institute of Bone and Joint Research, Royal North Shore Hospital, Sydney, Australia
  2. 2Department of Internal Medicine, Division of Rheumatology, University Hospital Maastrict and Caphri Research Institute, The Netherlands
  3. 3Department of Rheumatology, Hospital General de Mexico, Mexico
  4. 4Servicio de Reumatologia, Hospital Reina Sofia, Cordoba, Spain
  5. 5Division of Rheumatology, University of California San Francisco, San Francisco, USA
  6. 6Department of Rheumatology, VU University Medical Centre, Amsterdam, The Netherlands
  7. 7Service de Rheumatologie B, Hospital Cochin, Paris, France
  8. 8Department of Rheumatology and Physiotherapy, Semmelweis University, Budapest, Hungary
  9. 9Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
  10. 10Case Western Reserve University, University, MetroHealth Medical Center, Division of Rheumatology, Cleveland, Ohio, USA
  11. 11Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  12. 12Department of Medicine, Division of Rheumatology, Helsinki University Central Hospital, Helsinki, Finland
  13. 13Rheumatology Department of Lucania, S Carlo Hospital, Potenza and Madonna delle Grazie Hospital, Matera, Italy
  14. 14Institute of Rheumatology, Prague, Czech Republic
  15. 15Department of Gastroenterology and Rheumatology, Charitè, Campus Benjamin Franklin, Berlin, Germany
  16. 16Department of Physical Medicine and Rehabilitation, Ludwig-Maximilians-University, Munich, Germany
  17. 17Centre for Rheumatic Diseases, University Department of Medicine, Glasgow Royal Infirmary, Glasgow, UK
  18. 18Service de Rhumatologie, CHU Jean Minjoz, Besancon, France
  19. 19Department for Orthopaedics, Spinal Surgery and Paraplegiology, Zentralklinik Bad Berka, Bad Berka, Germany
  20. 20Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, The Netherlands
  21. 21Bochum University, Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Herne, Germany
  1. Correspondence to:
    Professor J Braun
    Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Landgrafenstr 15, 44652 Herne, Germany; J.Braun{at}


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.

  • 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
  • ankylosing spondylitis
  • management
  • recommendations
  • evidence based medicine
  • spondyloarthropathies
  • ASAS

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  • Published Online First 26 August 2005