To update and integrate the recommendations for ankylosing spondylitis and the recommendations for the use of tumour necrosis factor inhibitors (TNFi) in axial spondyloarthritis (axSpA) into one set applicable to the full spectrum of patients with axSpA. Following the latest version of the European League Against Rheumatism (EULAR) Standardised Operating Procedures, two systematic literature reviews first collected the evidence regarding all treatment options (pharmacological and non-pharmacological) that were published since 2009. After a discussion of the results in the steering group and presentation to the task force, overarching principles and recommendations were formulated, and consensus was obtained by informal voting. A total of 5 overarching principles and 13 recommendations were agreed on. The first three recommendations deal with personalised medicine including treatment target and monitoring. Recommendation 4 covers non-pharmacological management. Recommendation 5 describes the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice drug treatment. Recommendations 6–8 define the rather modest role of analgesics, and disprove glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for axSpA patents with predominant axial involvement. Recommendation 9 refers to biological DMARDs (bDMARDs) including TNFi and IL-17 inhibitors (IL-17i) for patients with high disease activity despite the use (or intolerance/contraindication) of at least two NSAIDs. In addition, they should either have an elevated C reactive protein and/or definite inflammation on MRI and/or radiographic evidence of sacroiliitis. Current practice is to start with a TNFi. Switching to another TNFi or an IL-17i is recommended in case TNFi fails (recommendation 10). Tapering, but not stopping a bDMARD, can be considered in patients in sustained remission (recommendation 11). The final two recommendations (12, 13) deal with surgery and spinal fractures. The 2016 Assessment of SpondyloArthritis international Society-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.
- DMARDs (biologic)
- Physcial therapy
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Contributors All authors were involved in the discussions and formulation of the recommendations. DvdH wrote the first version of the manuscript. All authors reviewed it and commented extensively on it. All authors approved the final version of the manuscript.
Funding European League Against Rheumatism and Assessment of SpondyloArthritis international Society.
Competing interests DvdH received consulting fees from AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boeringer Ingelheim, Celgene, Daiichi, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis, UCB and is Director of Imaging Rheumatology BV. RL received consulting fees from AbbVie, Ablynx, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Janssen, Galapagos, GlaxoSmithKline, Novartis, Novo-Nordisk, Merck, Pfizer, Rhoche, Schering-Plough, TiGenix, UCB and is Director of Rheumatology Consultancy BV. XB received consulting fees and research grants from AbbVie, Bristol-Myers Squibb, Celgene, Janssen, Novartis, Pfizer, Roche, MSD and UCB. FVdB received consulting and/or speaker fees from AbbVie, BMS, Celgene, Eli-Lilly, Janssen, Merck, Novartis, Pfizer and UCB. AC received consulting fees from AbbVie, Celgene, Eli-Lilly, Janssen-Cilag, Merck Sharp & Dohme, Novartis, Pfizer and UCB. MD received consulting fees from AbbVie, BMS, Boeringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis and UCB. FvG received consulting fees from Pfizer, MSD, AbbVie and Novartis. PG received consulting fees from AbbVie and Roche. IvdH-B received consulting fees from AbbVie, UCB and MSD and received unrestricted grants for investigator initiated studies from MSD, Pfizer and AbbVie. RDI received consulting fees from Amgen, Janssen, AbbVie, Novartis. UK received consultancy fees as well as grant and research support from AbbVie, Chugai, MSD, Novartis, Pfizer, Roche and UCB. TKK received consulting fees from AbbVie, Biogen, BMS, Boehringer Ingelheim, Celltrion, Eli-Lilly, Epirus, Janssen, Merck-Serono, MSD, Mundipharma, Novartis, Oktal, Orion Pharma, Hospira/Pfizer, Roche, Sandoz and UCB Pharma. PM received speaker/consulting fees from AbbVie, Centocor, Janssen, MSD, Novartis and Pfizer. HM-O received consulting fees from AbbVie, Celgene, Janssen, MSD, Novartis, Pfizer and UCB and grants from Janssen and Pfizer. AM received consulting fees and/or grants from AbbVie, Merck Pfizer and UCB. VN-C received consulting fees from AbbVie, BMS, Novartis, Pfizer, Roche and UCB. SO received consulting fees, speaking fees and/or honoraria from AbbVie, Pfizer, UCB, Merck Sharp & Dohme and Novartis. FMP-S received consulting fees from AbbVie, Celgene, Janssen, Novartis, Pfizer, Roche, Merck Sharp & Dohme, UCB, Biogen. JR received consulting fees from Janssen and is a participant in clinical trials of Janssen and Eli-Lilly. MR received consulting or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Chugai, Janssen, Novartis, Merck, Pfizer, Roche, UCB. JS received consulting fees from AbbVie, Boeringer Ingelheim, Eli-Lilly, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, UCB. PS-B received consulting fees from AbbVie, Janssen, Novartis, Pfizer, Roche, UCB. JB received research grants, honoraria, speaker fees and consultancy payments from AbbVie (Abbott), Amgen, Biogen, Boehringer Ingelheim, BMS, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Epirus, Hospira, Janssen, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis and UCB.
Provenance and peer review Not commissioned; externally peer reviewed.
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