2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

• Published in: Arthritis care & research (2010) Vol. 71; no. 10; pp. 1285 - 1299
• Main Authors: Ward, Michael M., Deodhar, Atul, Gensler, Lianne S., Dubreuil, Maureen, Yu, David, Khan, Muhammad Asim, Haroon, Nigil, Borenstein, David, Wang, Runsheng, Biehl, Ann, Fang, Meika A., Louie, Grant, Majithia, Vikas, Ng, Bernard, Bigham, Rosemary, Pianin, Michael, Shah, Amit Aakash, Sullivan, Nancy, Turgunbaev, Marat, Oristaglio, Jeff, Turner, Amy, Maksymowych, Walter P., Caplan, Liron
• Format: Journal Article
• Language: English
• Published: United States Wiley Subscription Services, Inc 01-10-2019
• Subjects: Ankylosing spondylitis; Antirheumatic Agents - therapeutic use; Arthritis; Axial skeleton; Biological products; Biomedical Research - methods; Biomedical Research - standards; Clinical Trials as Topic - methods; Clinical Trials as Topic - standards; Humans; Inflammatory diseases; Literature reviews; Magnetic resonance imaging; Methotrexate; Patients; Pelvis; Radiography; Rheumatic diseases; Rheumatology - methods; Rheumatology - standards; Spondylarthritis - diagnostic imaging; Spondylarthritis - epidemiology; Spondylarthritis - therapy; Spondylitis; Spondylitis, Ankylosing - diagnostic imaging; Spondylitis, Ankylosing - epidemiology; Spondylitis, Ankylosing - therapy; Sulfasalazine; Treatment Outcome; United States - epidemiology; United States
• ISSN: 2151-464X; 2151-4658; 2151-4658
• DOI: 10.1002/acr.24025

Objective
To update evidence‐based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).
Methods
We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat‐to‐target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel.
Results
Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co‐administration of low‐dose methotrexate with TNFi is not recommended, nor is a strict treat‐to‐target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended.
Conclusion
These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.