Table 1

Recommendations to treat all forms of Spondyloarthritis to target

		LoE	GoR	SoR
Overarching principles
A.	The treatment target must be based on a shared decision between patient and rheumatologist	5	D	9.7±0.8
B.	SpA and PsA are often complex systemic diseases; as needed, the management of musculoskeletal and extra-articular manifestations should be coordinated between the rheumatologist and other specialists (such as dermatologist, gastroenterologist, ophthalmologist)	5	D	9.5±0.92
C.	The primary goal of treating the patient with SpA and/or PsA is to maximise long-term health related quality of life and social participation through control of signs and symptoms, prevention of structural damage, normalisation or preservation of function, avoidance of toxicities and minimisation of comorbidities	5*	D	9.6±0.67
D.	Abrogation of inflammation is presumably important to achieve these goals	5*	D	9.1±1.04
E.	Treatment to target by measuring disease activity and adjusting therapy accordingly contributes to the optimisation of short term and/or long term outcomes	5*	D	9.2±1.11
Recommendations
Common items for all forms of SpA
1.	A major treatment target should be clinical remission/inactive disease of musculoskeletal involvement (arthritis, dactylitis, enthesitis, axial disease), taking extra-articular manifestations into consideration	5*	D	9.5±0.77
2.	The treatment target should be individualised according to the current clinical manifestations of the disease	5	D	9.3±1.03
3.	Clinical remission/inactive disease is defined as the absence of clinical and laboratory evidence of significant inflammatory disease activity	5	D	9.0±1.41
4.	Low/minimal disease activity may be an alternative treatment target	5*	D	9.4±0.91
5.	Disease activity should be measured on the basis of clinical signs and symptoms, and acute phase reactants	5*	D	9.4±1.14
6.	The choice of the measure of disease activity and the level of the target value may be influenced by considerations of comorbidities, patient factors and drug-related risks	5	D	9.4±1.02
7.	Once the target is achieved, it should ideally be maintained throughout the course of the disease	5*	D	9.4±0.76
8.	The patient should be appropriately informed and involved in the discussions about the treatment target, and the risks and benefits of the strategy planned to reach this target	5	D	9.8±0.50
9.	Structural changes, functional impairment, extra-articular manifestations, comorbidities and treatment risks should be considered when making clinical decisions, in addition to assessing measures of disease activity	5	D	9.5±0.81
Specific items for individual types of Spondyloarthritis
Axial Spondyloarthritis (including ankylosing spondylitis)
10.	Validated composite measures of disease activity such as the BASDAI plus acute phase reactants or the Ankylosing Spondylitis Disease Activity Score, with or without measures of function such as BASFI, should be performed and documented regularly in routine clinical practice to guide treatment decisions; the frequency of the measurements depends on the level of disease activity	5	D	9.3±0.95
11.	Other factors, such as axial inflammation on MRI, radiographic progression, peripheral musculoskeletal and extra-articular manifestations, as well as comorbidities may also be considered when setting clinical targets	5*	D	9.3±0.80
Peripheral Spondyloarthritis
10.	Quantified measures of disease activity, which reflect the individual peripheral musculoskeletal manifestations (arthritis, dactylitis, enthesitis) should be performed and documented regularly in routine clinical practice to guide treatment decisions; the frequency of the measurements depends on the level of disease activity	5	D	9.3±0.85
11.	Other factors. such as spinal and extra-articular manifestations, imaging results, changes in function/quality of life, as well as comorbidities may also be considered for decision	5	D	9.4±0.78
Psoriatic arthritis
10.	Validated measures of musculoskeletal disease activity (arthritis, dactylitis, enthesitis, axial disease) should be performed and documented regularly in routine clinical practice to guide treatment decisions; the frequency of the measurements depends on the level of disease activity; cutaneous manifestations should also be considered	5	D	9.4±0.78
11.	Other factors, such as spinal and extra-articular manifestations, imaging results, changes in function/quality of life, as well as comorbidities may also be considered for decision	5	D	9.3±1.00

An asterisk in the LoE column denotes that for this item indirect evidence is available from the literature search which was nevertheless not sufficient for a higher grading of the evidence level.
BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; BASFI, Bath Ankylosing Spondylitis Functional Index; GoR, grade of recommendation; LoE, level of evidence; PsA, psoriatic arthritis; SoR, strength of recommendation (level of agreement); SpA, spondyloarthritis.