Experts’ propositions developed through three Delphi rounds—order according to topic (general, non-pharmacological, pharmacological, invasive, and surgical)
| No | Proposition |
|---|---|
| AS, ankylosing spondylitis; GI, gastrointestinal; NSAIDs, non-steroidal anti-inflammatory drugs; DMARDs, disease modifying antirheumatic drugs; TNF, tumour necrosis factor. | |
| 1 | Treatment of AS should be tailored according to: |
| • Current manifestations of the disease (axial, peripheral, entheseal, extra-articular symptoms and signs) | |
| • Level of current symptoms, clinical findings, and prognostic indicators | |
| - Disease activity/inflammation | |
| - Pain | |
| - Function, disability, handicap | |
| - Structural damage, hip involvement, spinal deformities | |
| • General clinical status (age, sex, comorbidity, concomitant drugs) | |
| • Wishes and expectations of the patient | |
| 2 | Disease monitoring of patients with AS should include: patient history (for example, questionnaires), clinical parameters, laboratory tests, and imaging, all according to the clinical presentation, as well as the ASAS core set. The frequency of monitoring should be decided on an individual basis depending on symptoms, severity, and drug treatment |
| 3 | Optimal management of AS requires a combination of non-pharmacological and pharmacological treatments |
| 4 | Non-pharmacological treatment of AS should include patient education and regular exercise. Individual and group physical therapy should be considered. Patient associations and self help groups may be useful |
| 5 | NSAIDs are recommended as first line drug treatment for patients with AS with pain and stiffness. In those with increased GI risk, non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor could be used |
| 6 | Analgesics, such as paracetamol and opioids, might be considered for pain control in patients in whom NSAIDs are insufficient, contraindicated, and/or poorly tolerated |
| 7 | Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered. The use of systemic corticosteroids for axial disease is not supported by evidence |
| 8 | There is no evidence for the efficacy of DMARDs, including sulfasalazine and methotrexate, for the treatment of axial disease. Sulfasalazine may be considered in patients with peripheral arthritis |
| 9 | Anti-TNF treatment should be given to patients with persistently high disease activity despite conventional treatments according to the ASAS recommendations. There is no evidence to support the obligatory use of DMARDs before, or concomitant with, anti-TNF treatment in patients with axial disease |
| 10 | Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age. Spinal surgery—for example, corrective osteotomy and stabilisation procedures, may be of value in selected patients |