Article Text

2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis
  1. Désirée van der Heijde1,
  2. Sofia Ramiro1,
  3. Robert Landewé2,3,
  4. Xenofon Baraliakos4,
  5. Filip Van den Bosch5,
  6. Alexandre Sepriano1,6,
  7. Andrea Regel4,
  8. Adrian Ciurea7,
  9. Hanne Dagfinrud8,
  10. Maxime Dougados9,10,
  11. Floris van Gaalen1,
  12. Pál Géher11,
  13. Irene van der Horst-Bruinsma12,
  14. Robert D Inman13,
  15. Merryn Jongkees14,
  16. Uta Kiltz4,
  17. Tore K Kvien15,
  18. Pedro M Machado16,
  19. Helena Marzo-Ortega17,18,
  20. Anna Molto9,10,
  21. Victoria Navarro-Compàn19,
  22. Salih Ozgocmen20,
  23. Fernando M Pimentel-Santos21,
  24. John Reveille22,
  25. Martin Rudwaleit23,24,25,
  26. Jochen Sieper26,
  27. Percival Sampaio-Barros27,
  28. Dieter Wiek28,
  29. Jürgen Braun4
  1. 1Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  2. 2Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
  3. 3Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
  4. 4Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Herne, Germany
  5. 5Department of Rheumatology, Ghent University and Ghent University Hospital, Ghent, Belgium
  6. 6NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
  7. 7Department of Rheumatology, University Hospital Zurich, Zurich Switzerland
  8. 8Diakonhjemmet Hospital, Oslo, Norway
  9. 9Paris Descartes University, Hôpital Cochin, Assistance Publique—Hôpitaux de Paris, Paris, France
  10. 10INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France
  11. 11Semmelweis University, Budapest, Hungary
  12. 12Department of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
  13. 13University of Toronto, Toronto, Ontario, Canada
  14. 14Patient Research Partner, Amsterdam, The Netherlands
  15. 15Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  16. 16Centre for Rheumatology & MRC Centre for Neuromuscular Diseases, University College London, London, UK
  17. 17NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds, UK
  18. 18Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK
  19. 19Department of Rheumatology, University Hospital La Paz, IdiPaz, Madrid, Spain
  20. 20Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Erciyes University, Kayseri, Turkey
  21. 21NOVA Medical School, NOVA University of Lisbon, Lisboa, Portugal
  22. 22The University of Texas-Health McGovern Medical School, Dallas, USA
  23. 23Klinikum Bielefeld, Bielefeld, Germany
  24. 24Gent University, Gent, Belgium
  25. 25Charité University Medicine, Berlin, Germany
  26. 26Department of Rheumatology, Campus Benjamin Franklin, Charité, Berlin, Germany
  27. 27Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
  28. 28EULAR PARE Patient Research Partner and Chair of EULAR PARE, Berlin, Germany
  1. Correspondence to Professor Désirée van der Heijde, Department of Rheumatology, Leiden University Medical Center, PO Box 9600, Leiden 2300 RC, The Netherlands; mail{at}


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.

  • Spondyloarthritis
  • Treatment
  • NSAIDs
  • DMARDs (biologic)
  • Physcial therapy

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Supplementary materials

  • Lay summary

    Disclaimer : This is a summary of a scientific article written by a medical professional (“the Original Article”). The Summary is written to assist non medically trained readers to understand general points of the Original Article. It is supplied “as is” without any warranty. You should note that the Original Article (and Summary) may not be fully relevant nor accurate as medical science is constantly changing and errors can occur. It is therefore very important that readers not rely on the content in the Summary and consult their medical professionals for all aspects of their health care and only rely on the Summary if directed to do so by their medical professional. Please view our full Website Terms and Conditions.
    Copyright © 2017 BMJ Publishing Group Ltd & European League Against Rheumatism. Medical professionals may print copies for their and their patients and students non commercial use. Other individuals may print a single copy for their personal, non commercial use. For other uses please contact our Rights and Licensing Team.


  • 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.

Linked Articles