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Arthritis Care Res (Hoboken). 2019 Aug 21. doi: 10.1002/acr.24025. [Epub ahead of print]

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.

Author information

1
National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland.
2
Oregon Health & Science University, Portland.
3
University of California, San Francisco.
4
Boston University School of Medicine, Boston, Massachusetts.
5
University of California, Los Angeles.
6
Case Western Reserve University, Cleveland, Ohio.
7
University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada.
8
Arthritis & Rheumatism Associates, Washington, DC.
9
Columbia University Medical Center, New York, New York.
10
VA West Los Angeles Medical Center, Los Angeles, California.
11
Arthritis and Rheumatism Associates, Wheaton, Maryland.
12
University of Mississippi Medical Center, Jackson.
13
University of Washington, Seattle.
14
Seattle, Washington.
15
Pianin and Associates, PC, Phoenix, Arizona.
16
American College of Rheumatology, Atlanta, Georgia.
17
ECRI Institute, Plymouth Meeting, Pennsylvania.
18
University of Alberta, Edmonton, Alberta, Canada.
19
Rocky Mountain Regional VA Medical Center and University of Colorado, Aurora.

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.

PMID:
31436026
DOI:
10.1002/acr.24025

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