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
...atment...
...ommendations for the Treatment of Adults With AS (...
...e strongly recommend treatment with...
.... We conditionally recommend continuous treatment...
...do not recommend any particular NSA...
...th active AS despite treatment with NS...
...adults with active AS despite treatment...
...ith active AS despite treatment with NSAIDs,...
...o not recommend any particular TNFi as the...
...s with active AS despite treatment with N...
...ults with active AS despite treatment...
...lts with active AS despite treatment with NSAIDs...
...s with active AS despite treatment with N...
...lts with active AS despite treatment with the...
.... In adults with active AS despite tre...
...ith active AS despite treatment wit...
...th active AS despite treatment with the first...
...rongly recommend against treatment with syste...
...ith isolated active sacroiliitis despite treatment...
...In adults with stable axial disease and active en...
...n adults with stable axial disease and active pe...
...strongly recommend treatment with physical t...
...e conditionally recommend active physical...
...tionally recommend land-based physical...
...ecommendations for Adults With...
...ditionally recommend on-demand treatment...
...n adults receiving treatment with TNF...
...ults receiving treatment with TNFi and a conventi...
26. In adults receiving treatment with a biolo...
...adults receiving treatment with a biolo...
.... In adults receiving treatment with a...
...gly recommend treatment with physica...
...mmendations for Adults With Active...
30. In adults receiving treatment with TNF...
.... We conditionally recommend advis...
...tionally recommend fall evaluation and c...
...ditionally recommend participation in form...
...th spinal fusion or advanced spinal osteoporos...
...n adults with advanced hip arthriti...
...adults with severe kyphosis, we cond...
...ndations for Adults With AS-Related Comorbidities...
...ith acute iritis, we strongly recommen...
...adults with recurrent iritis, we conditionall...
...with recurrent iritis, we conditionally recommend...
...ults with inflammatory bowel disease, we do no...
...th inflammatory bowel disease, we conditiona...
...Activity Assessment, Imaging, and Screening...
...ionally recommend the regular-interval use and...
...We conditionally recommend regular-interva...
...adults with active AS, we conditionally...
...onally recommend screening for osteop...
...with syndesmophytes or spinal fusion, we condi...
...e strongly recommend against scree...
...y recommend against screening for v...
...th AS of unclear activity while on...
...adults with stable AS, we conditi...
...s with active or stable AS on any treatment, we...
...commendations were from 2015 and w...
...ecommendations for the Treatment of Adults Wit...
...for Adults With Active Nonradiographi...
...strongly recommend treatment with NSAIDs over no...
.... We conditionally recommend continuous...
...not recommend any particular NSAID as the preferre...
...adults with active nonradiographic ax...
.... In adults with active nonradiographic...
...recommend any particular TNFi as the pref...
...dults with active nonradiographic ax...
...ults with active nonradiographic axial SpA...
...adults with active nonradiographic axial SpA desp...
...lts with active nonradiographic axial Sp...
...In adults with active nonradiographi...
...adults with active nonradiographic ax...
...ith active nonradiographic axial SpA and s...
...with active nonradiographic axial SpA despite tre...
...adults with active nonradiographic axial...
...We strongly recommend against treatment...
...with isolated active sacroiliitis despite treatme...
...with active enthesitis despite trea...
...lts with active peripheral arthritis despite trea...
...ngly recommend treatment with physical...
...nally recommend active physical therapy interve...
73. We conditionally recommend land-based...
...commendations for Adults With Stabl...
...ally recommend on-demand treatment wi...
...In adults receiving treatment with TNFi and NSA...
...adults receiving treatment with TNF...
...7. In adults receiving treatment with a biol...
...s receiving treatment with a biologic...
...ceiving treatment with an originator TNFi, we stro...
...ns for Adults With Active or Stable Nonradiograph...
...s receiving treatment with TNFi, we c...
...ctivity Assessment and Imag...
...e conditionally recommend the regular-...
...onally recommend regular-interval...
...adults with active nonradiographic axial SpA, w...
...adults with nonradiographic axial...
...ults with stable nonradiographic axial SpA, we...
86. In adults with active or stable nonradiogra...
...ommendations were from 2015 and were not rev...
...ure 1A. Treatment of Patients With...
...Treatment of Patients With Stable AS...