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

Michael M. Ward(National Institute of Arthritis and Musculoskeletal and Skin Diseases), Atul Deodhar(Oregon Health & Science University), Lianne S. Gensler(University of California, San Francisco), Maureen Dubreuil(Boston University), David Tak Yan Yu(University of California, Los Angeles), Muhammad Asim Khan(Case Western Reserve University), Nigil Haroon(University of Toronto), David Borenstein(Arthritis and Rheumatism Associates), Runsheng Wang(Columbia University Irving Medical Center), Ann Biehl(National Institute of Arthritis and Musculoskeletal and Skin Diseases), Meika A. Fang(VA West Los Angeles Medical Center), Grant H. Louie(Arthritis and Rheumatism Associates), Vikas Majithia(Jackson Memorial Hospital), Bernard Ng(University of Washington), Rosemary Bigham, Michael Pianin, Amit Shah(American College of Rheumatology), Nancy Sullivan(ECRI Institute), Marat Turgunbaev(American College of Rheumatology), Jeff Oristaglio(ECRI Institute), Amy S. Turner(American College of Rheumatology), Walter P. Maksymowych(University of Alberta), Liron Caplan(Rocky Mountain MS Center)
Arthritis Care & Research
August 21, 2019
10.1002/acr.24025
Cited by 688Open Access
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Abstract

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.

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