Axial spondyloarthritis (axSpA) is a chronic rheumatic disease that is typically characterized by inflammation of the sacroiliac joints and spine. This inflammation typically results in back pain and stiffness, and may lead to ankylosis. The disease may be diagnosed as either ankylosing spondylitis or nonradiographic axSpA, depending on the presence of radiographic sacroiliitis. Unfortunately, axSpA is often misdiagnosed or not diagnosed for several years after the onset of symptoms because the back pain associated with the disease can be difficult to distinguish from other causes of back pain.
The Assessment of SpondyloArthritis International Society (ASAS), in collaboration with the European League Against Rheumatism (EULAR), have published an update to the 2010 guidelines for the management of axSpA, which refers to the whole spectrum of patients with and without radiographic sacroiliitis (van der Heijde D, et al. Ann Rheum Dis. 2017;76:978-991).
In seeking to provide guidance regarding the pharmacologic and nonpharmacologic management of patients with axSpA, ASAS-EULAR updated and combined management recommendations for ankylosing spondylitis that they had previously established with existing ASAS recommendations for the management of axSpA. These updates specifically pertain to the use of tumor necrosis factor inhibitors (TNFis), and are designed to be applicable to all patients with axSpA.
“ASAS-EULAR recommendations for the management of axSpA provide in a single set of recommendations guidance for the management of patients from the whole spectrum of the disease, including radiographic and non-radiographic axSpA, and address the whole disease management, including non-pharmacological and pharmacological treatment,” explained lead author Désirée van der Heijde, MD, Professor of Rheumatology, Leiden University Medical Center, The Netherlands, and colleagues.
Using the 2014 EULAR standardized operating procedures, a task force designated by ASAS-EULAR that included 39 members who represented 14 nations in Europe, North America, and South America reviewed the results of 2 systematic literature reviews, carried out by 2 fellows to gather evidence published since 2009 that pertained to all treatment options.
A total of 13 recommendations, under the umbrella of 5 overarching principles, were agreed upon by the task force based on the results of the systematic literature reviews.
Updated Recommendations for the Management of Axial SpondyloarthritisOverarching Principles
- Because of its potential for severity and diverse manifestations, axSpA generally requires multidisciplinary management that is coordinated by a rheumatologist
- Improving long-term health-related quality of life is the primary goal of treating patients with axSpA, and that outcome can be pursued by controlling symptoms and inflammation, preventing structural damage, and preserving function and social participation
- A combination of pharmacologic and nonpharmacologic treatment methods are needed to achieve optimal management of axSpA
- axSpA treatment should be directed toward optimal care and based on shared decision-making between the patient and the rheumatologist
- The high costs associated with axSpA should be factored in by the rheumatologist when tailoring management strategies.
- axSpA treatment should be individualized based on current signs and symptoms of the disease (ie, axial, peripheral, extra-articular manifestations), and on patient characteristics (eg, comorbidities and psychosocial factors)
- Disease monitoring should be conducted with suitable tools, and comprise patient-reported outcomes, clinical findings, laboratory tests, and imaging; monitoring frequency should be individualized, depending on symptoms, disease severity, and therapy
- Therapy should be directed in accordance with a previously defined treatment target
- Educate patients about axSpA, and encourage them to stop smoking and exercise regularly; physical therapy should also be considered
- Factoring in risks and benefits, nonsteroidal anti-inflammatory drugs, given up to the maximum dose, should be used as first-line therapy in patients with pain and stiffness; continuous use of these drugs is preferred in symptomatic patients who respond well to them
- In situations where previously recommended treatments fail, are contraindicated, and/or are poorly tolerated, analgesics (eg, paracetamol and opioidlike drugs) may be considered to alleviate residual pain
- Consider therapy with glucocorticoid injections directed to the musculoskeletal inflammation site; however, long-term treatment with systemic glucocorticoids should not be administered to patients with axial disease
- It is generally not advised that patients with purely axial disease receive treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARDs); however, sulfasalazine is an option for patients with peripheral arthritis
- Although current practice recommends starting with TNFi therapy, biologic DMARDs should be considered in patients who receive conventional therapies and have persistently high disease activity
- Consider switching to an alternative TNFi or interleukin-17 inhibitor therapy in the event that TNFi therapy is unsuccessful
- Consider tapering biologic DMARDs in patients who have sustained disease remission
- In patients who have refractory pain or disability and radiographic evidence of structural damage, total hip arthroplasty should be considered, regardless of age; spinal corrective osteotomy is a potential option for patients with severe disabling deformities
- In the event of a significant variation in disease course, perform an appropriate evaluation (eg, imaging), and consider causes other than inflammation (eg, a spinal fracture).
Dr van der Heijde and colleagues explained the benefits of the new set of management guidelines.
“The integrated set is more ‘user friendly’ and clearer to users than two separate sets,” they wrote.
They also posited that the long period between this update and the last version of the guidelines—published in 2010—was because, until recently, there had been a lack of new treatment options.
“The next update will be undertaken when there are sufficient new data on existing treatments or when data on new treatment options will become available. Until then, we hope that the current recommendations will be useful for healthcare professionals taking care of patients with axSpA, for patients themselves, for the pharmaceutical industry and for payers,” they concluded.