2016 Update of the ASAS-EULAR recommendations for the management of axSpA
| Overarching principles | LoE | GoR | LoA (0–10) | |
|---|---|---|---|---|
| 1 | axSpA is a potentially severe disease with diverse manifestations, usually requiring multidisciplinary management coordinated by the rheumatologist | 9.9 (0.31) 100% ≥8 | ||
| 2 | The primary goal of treating the patient with axSpA is to maximise health-related quality of life through control of symptoms and inflammation, prevention of progressive structural damage, preservation/normalisation of function and social participation | 9.8 (0.47) 100% ≥8 | ||
| 3 | The optimal management of patients with axSpA requires a combination of non-pharmacological and pharmacological treatment modalities | 9.8 (0.45) 100% ≥8 | ||
| 4 | Treatment of axSpA should aim at the best care and must be based on a shared decision between the patient and the rheumatologist | 9.5 (0.91) 100% ≥8 | ||
| 5 | axSpA incurs high individual, medical and societal costs, all of which should be considered in its management by the treating rheumatologist | 9.3 (1.17) 97% ≥8 | ||
| Recommendations | ||||
| 1 | The treatment of patients with axSpA should be individualised according to the current signs and symptoms of the disease (axial, peripheral, extra-articular manifestations) and the patient characteristics including comorbidities and psychosocial factors | 5 | D | 9.7 (0.65) 100% ≥8 |
| 2 | Disease monitoring of patients with axSpA should include patient-reported outcomes, clinical findings, laboratory tests and imaging, all with the appropriate instruments and relevant to the clinical presentation. The frequency of monitoring should be decided on an individual basis depending on symptoms, severity and treatment | 5 | D | 9.6 (0.78) 100% ≥8 |
| 3 | Treatment should be guided according to a predefined treatment target | 5 | D | 8.9 (1.45) 93% ≥8 |
| 4 | Patients should be educated* about axSpA and encouraged to exercise* on a regular basis and stop smoking‡; physical therapy† should be considered | 2* 5‡ 1a† | B* D‡ A† | 9.6 (0.78) 100% ≥8 |
| 5 | Patients suffering from pain and stiffness should use an NSAID as first-line drug treatment up to the maximum dose, taking risks and benefits into account. For patients who respond well to NSAIDs continuous use is preferred if symptomatic otherwise | 1a | A | 9.4 (0.94) 100% ≥8 |
| 6 | Analgesics, such as paracetamol and opioid-(like) drugs, might be considered for residual pain after previously recommended treatments have failed, are contraindicated, and/or poorly tolerated | 5 | D | 8.8 (0.94) 100% ≥8 |
| 7 | Glucocorticoid injections* directed to the local site of musculoskeletal inflammation may be considered. Patients with axial disease should not receive long-term treatment with systemic glucocorticoids‡ | 2* 5‡ | B* D‡ | 9.4 (0.78) 100% ≥8 |
| 8 | Patients with purely axial disease should normally not be treated with csDMARDs§; sulfasalazine† may be considered in patients with peripheral arthritis | 1a† | A | 9.2 (0.78) 100% ≥8 |
| 9 | bDMARDs should be considered in patients with persistently high disease activity despite conventional treatments (figure 1); current practice is to start with TNFi therapy | 1a (TNFi); 1b (IL-17i) | A | 9.6 (1.09) 93% ≥8 |
| 10 | If TNFi therapy fails, switching to another TNFi* or IL-17i** therapy should be considered | 2* 1b** | B* A** | 9.6 (0.95) 97% ≥8 |
| 11 | If a patient is in sustained remission, tapering of a bDMARD can be considered | 2 | B | 9.1 (1.57) 97% ≥8 |
| 12 | Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age; spinal corrective osteotomy in specialised centres may be considered in patients with severe disabling deformity | 4 | C | 9.4 (0.82) 100% ≥8 |
| 13 | If a significant change in the course of the disease occurs, causes other than inflammation, such as a spinal fracture, should be considered and appropriate evaluation, including imaging, should be performed | 5 | D | 9.9 (0.31) 97% ≥8 |
§1a (sulfasalazine; methotrexate); 1b (leflunomide); 4 other csDMARDs.
axSpA, axial spondyloarthritis; bDMARD, biological disease-modifying antirheumatic drug; csDMARD, conventional synthetic disease-modifying antirheumatic drug; GoR, grade of recommendation; IL-17i, interleukin-17 inhibitor; LoA, level of agreement; LoE, level of evidence; NSAIDs, non-steroidal anti-inflammatory drugs; TNFi, tumour necrosis factor inhibitor.