Rheumatologic disorders

Leading Organizations Issue Updated Guideline for Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

The American College of Rheumatology (ACR), the Spondylitis Association of America (SAA), and the Spondyloarthritis Research and Treatment Network (SPARTAN) have released an updated clinical guideline1 for the management and treatment of ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). The revised guideline specifically addresses new medications, as well as considerations for the use of biosimilars and imaging.

The guideline, which is an update of the ACR/SAA/SPARTAN recommendations published in 2015,2,3 comes after the authors performed a systematic literature review for 20 clinical questions on pharmacologic treatment that had been addressed in the previous guideline and for 26 new questions on pharmacologic treatment, treat‐to‐target strategy, and use of imaging.

“Based on the literature, we felt it was important to address topics such as sequencing biologics for patients with active AS despite NSAID usage, whether to taper or discontinue biologics in the setting of remission, and clearer guidelines on when to obtain images, particularly in instances when results would likely lead to a change in treatment,” Michael Ward, MD, MPH, a researcher at the National Institute of Arthritis and Musculoskeletal and Skin Diseases and lead author of the guideline, said in a press release.2

Among the recommendations based on conditional or strong evidence from available literature are the following:

  • A tumor necrosis factor inhibitor (TNFi) should be first-line treatment over secukinumab or ixekizumab.
  • Secukinumab or ixekizumab should be used over a second TNFi in patients who experience primary nonresponse to the initial TNFi treatment.
  • The use of a TNFi, secukinumab, or ixekizumab is preferred over tofacitinib.
  • For adults with stable AS, treatment with the original biologic should be considered over mandated switching to its biosimilar.
  • Among patients with stable disease, combined administration of low‐dose methotrexate and a TNFi, implementation of a strict treat‐to‐target strategy, or discontinuation/tapering of biologics should not be considered.
  • Sulfasalazine should only be used for persistent peripheral arthritis when TNFi are contraindicated.
  • Spine or pelvis magnetic resonance imaging may aid assessment among patients with unclear disease activity.
  • Routine monitoring of radiographic changes with serial spine radiography should not be considered.

 

“Application of these recommendations must be individualized, and requires careful assessment, sound clinical judgment of each patient’s circumstances, and consideration of a patient’s preferences,” the authors concluded.

—Melinda Stevens

References:

  1. Ward MM, Deodhar A, Gensler LS, et al. 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 online August 21, 2019]. Arthritis Care Res (Hoboken). doi:10.1002/acr.24025.
  2. Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Care Res (Hoboken). 2016;68(2):282-298. doi:10.1002/acr.22708.
  3. Rheumatology and spondylitis organizations release updated treatment guideline for axial spondyloarthritis [press release]. Atlanta, GA: American College of Rheumatology; August 22, 2019. https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1033. Accessed August 23, 2019.