Ankylosing Spondylitis
Key Points
Key Points
- Axial spondyloarthritis (SpA), comprising ankylosing spondylitis (AS) and nonradiographic axial SpA, is the main form of chronic inflammatory arthritis affecting the axial skeleton.
- AS affects 0.1–0.5% of the population and is characterized by inflammatory back pain, radiographic sacroiliitis, excess spinal bone formation, and a high prevalence of HLA–B27.
- The severity of arthralgia, stiffness, and limited flexibility varies widely among patients and over the course of axial SpA.
- Skeletal disease may be accompanied by uveitis, psoriasis, and inflammatory bowel disease (IBD).
- The goals of treatment are to alleviate symptoms, improve functioning, maintain the ability to work, decrease disease complications, and forestall skeletal damage as much as possible.
Table 1. Definitions of Key Terms
| Term | Definition |
| Active disease | Disease causing symptoms at an unacceptably bothersome level to the patient and judged by the examining clinician to be due to inflammation. |
| Stable disease | Disease that was asymptomatic or causing symptoms but at an acceptable level as reported by the patient. A minimum of 6 months was required to qualify as clinically stable. |
| Primary nonresponse | Absence of a clinically meaningful improvement in disease activity over the 3 to 6 months after treatment initiation, not related to toxicity or poor adherence. |
| Secondary nonresponse | Recurrence of ankylosing spondylitis activity, not due to treatment interruption or poor adherence, after having a sustained clinically meaningful improvement on treatment (generally, beyond the initial 6 months of treatment). |
| Conventional synthetic antirheumatic drug | Sulfasalazine, methotrexate, leflunomide, apremilast, thalidomide, pamidronate. |
| Biosimilar | Biopharmaceuticals that are copies of an original biologic medication and tested to be of the same purity and potency as the original. In these recommendations, we refer only to TNFi biosimilars. Examples include infliximab-dyyb, etanercept-szzs, and adalimumab-atto. |
| TNFi | Infliximab, etanercept, adalimumab, certolizumab, golimumab, and their biosimilars. |
| TNFi monoclonal antibodies | Infliximab, adalimumab, certolizumab, golimumab. |
| Biologics | TNFi, abatacept, rituximab, sarilumab, tocilizumab, ustekinumab, secukinumab, ixekizumab |
| Patient preferences | Beliefs and expectations regarding potential benefits and harms of treatment and how these relate to an individual’s goals for health and life. |
| Shared decision-making | The process by which a patient and clinician arrive at an individualized treatment decision based on an understanding of the potential benefits and risks of available treatment options and of a patient’s values and preferences. |
Treatment
Treatme...
...ndations for the Treatment of Adults With AS (Tabl...
...ngly recommend treatment with NSAIDs...
...We conditionally recommend continuous t...
.... We do not recommend any particular NSAID as...
...ith active AS despite treatment with NSAIDs, we c...
...adults with active AS despite treatment with N...
...s with active AS despite treatment wi...
...do not recommend any particular TNFi as the...
...s with active AS despite treatment with...
...th active AS despite treatment with...
...with active AS despite treatment with NSAIDs,...
...dults with active AS despite treatment with NSAIDs...
...lts with active AS despite treatment w...
.... In adults with active AS despite treatment wi...
...ults with active AS despite treatment with...
.... In adults with active AS despite treatment with...
...6. We strongly recommend against treatme...
...n adults with isolated active sacroiliiti...
...adults with stable axial disease and active...
...n adults with stable axial disease...
...y recommend treatment with physical therapy over...
...e conditionally recommend active physical therapy...
...e conditionally recommend land-based...
...ons for Adults With Stable AS...
...onditionally recommend on-demand treatment with N...
...s receiving treatment with TNFi and NSAIDs, we c...
...In adults receiving treatment with TNFi a...
...s receiving treatment with a biologic, we cond...
...adults receiving treatment with a biolo...
...receiving treatment with an originator...
...rongly recommend treatment with physica...
...ns for Adults With Active or Stable AS...
...lts receiving treatment with TNFi, we conditi...
...nally recommend advising unsupervised back exer...
...onally recommend fall evaluation and co...
...conditionally recommend participation...
...adults with spinal fusion or advanced spinal...
...ults with advanced hip arthritis, we strongly...
...ts with severe kyphosis, we conditionally recomm...
...mendations for Adults With AS-Related Comor...
...ults with acute iritis, we strongly recommend tre...
38. In adults with recurrent iritis, we cond...
...s with recurrent iritis, we condition...
...lts with inflammatory bowel disease, we do not re...
...adults with inflammatory bowel disease,...
...ctivity Assessment, Imaging, and Screening...
...nally recommend the regular-interval use...
...3. We conditionally recommend regular-interval...
...In adults with active AS, we conditional...
...ally recommend screening for osteopenia/osteopo...
46. In adults with syndesmophytes or spinal f...
...e strongly recommend against screening for cardia...
...e strongly recommend against screening for...
...ith AS of unclear activity while on...
...lts with stable AS, we conditionally recom...
...lts with active or stable AS on any treatment, we...
...These recommendations were from 2015 and were not...
...ndations for the Treatment of Adults W...
...for Adults With Active Nonradiograph...
...We strongly recommend treatment with N...
...e conditionally recommend continuous treatment...
...recommend any particular NSAID as t...
...In adults with active nonradiographic axial Sp...
...n adults with active nonradiographic axia...
...not recommend any particular TNFi...
...adults with active nonradiographic axial SpA desp...
...s with active nonradiographic axial...
...lts with active nonradiographic axial SpA des...
...s with active nonradiographic axial SpA de...
62. In adults with active nonradiographic axia...
...s with active nonradiographic axial...
...ts with active nonradiographic axial SpA and seco...
.... In adults with active nonradiographic ax...
...dults with active nonradiographic axial SpA desp...
...We strongly recommend against trea...
...adults with isolated active sacroiliitis d...
...s with active enthesitis despite treatment with N...
...s with active peripheral arthritis d...
...strongly recommend treatment with p...
...itionally recommend active physical...
...ditionally recommend land-based physical thera...
...for Adults With Stable Nonradiographic Axial...
...We conditionally recommend on-demand treat...
...5. In adults receiving treatment w...
...dults receiving treatment with TNFi an...
...s receiving treatment with a biologic, w...
...In adults receiving treatment with a biologi...
79. In adults receiving treatment with...
...ions for Adults With Active or Stable No...
...s receiving treatment with TNFi, we co...
...sease Activity Assessment a...
...nally recommend the regular-interval use a...
...conditionally recommend regular-interval use and m...
...adults with active nonradiographic axial SpA, we...
...lts with nonradiographic axial SpA of u...
.... In adults with stable nonradiographic axial SpA,...
...ts with active or stable nonradiographic axial SpA...
a These recommendations were from 2015 a...
...eatment of Patients With Active AS...
...atment of Patients With Stable AS...