Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

Publication Date: August 22, 2019
Last Updated: December 15, 2022

Treatment

Recommendations for the Treatment of Adults With AS (Table 2)

1. We strongly recommend treatment with NSAIDs over no treatment with NSAIDsa. ( Moderate , )
608
2. We conditionally recommend continuous treatment with NSAIDs over on-demand treatment with NSAIDs. ( Moderate , )
608
3. We do not recommend any particular NSAID as the preferred choice.a ( Moderate , )
608
4. In adults with active AS despite treatment with NSAIDs, we conditionally recommend treatment with sulfasalazine, methotrexate, or tofacitinib over no treatment with these medications. Sulfasalazine or methotrexate should be considered only in patients with prominent peripheral arthritis or when TNFi are not available. (Low to moderate, )
608
5. In adults with active AS despite treatment with NSAIDs, we conditionally recommend treatment with TNFi over treatment with tofacitinib. (Very low-quality evidence)
608
6. In adults with active AS despite treatment with NSAIDs, we strongly recommend treatment with TNFi over no treatment with TNFi. (High-quality evidence)
608
7. We do not recommend any particular TNFi as the preferred choice. (Moderate to high, )
608
8. In adults with active AS despite treatment with NSAIDs, we strongly recommend treatment with secukinumab or ixekizumab over no treatment with secukinumab or ixekizumab. ( High , )
608
9. In adults with active AS despite treatment with NSAIDs, we conditionally recommend treatment with TNFi over treatment with secukinumab or ixekizumab. (Low to moderate, )
608
10. In adults with active AS despite treatment with NSAIDs, we conditionally recommend treatment with secukinumab or ixekizumab over treatment with tofacitinib. (Very low-quality evidence)
608
11. In adults with active AS despite treatment with NSAIDs and who have contraindications to TNFi, we conditionally recommend treatment with secukinumab or ixekizumab over treatment with sulfasalazine, methotrexate, or tofacitinib. ( Moderate , )
608
12. In adults with active AS despite treatment with the first TNFi used, we conditionally recommend treatment with secukinumab or ixekizumab over treatment with a different TNFi in patients with primary nonresponse to TNFi. (Low to moderate, )
608
13. In adults with active AS despite treatment with the first TNFi used, we conditionally recommend treatment with a different TNFi biologic in patients with secondary nonresponse to TNFi. (Low to moderate, )
608
14. In adults with active AS despite treatment with the first TNFi used, we strongly recommend against switching to treatment with a biosimilar of the first TNFi. (Low to moderate, )
608
15. In adults with active AS despite treatment with the first TNFi used, we conditionally recommend against the addition of sulfasalazine or methotrexate in favor of treatment with a new biologic. (Low to moderate, )
608
16. We strongly recommend against treatment with systemic glucocorticoids.a (Low to moderate, )
608
17. In adults with isolated active sacroiliitis despite treatment with NSAIDsa, we conditionally recommend treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. (Low to moderate, )
608
18. In adults with stable axial disease and active enthesitis despite treatment with NSAIDsa, we conditionally recommend using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. Peri-tendon injections of Achilles, patellar, and quadriceps tendons should be avoided. (Low to moderate, )
608
19. In adults with stable axial disease and active peripheral arthritis despite treatment with NSAIDsa, we conditionally recommend using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. (Low to moderate, )
608
20. We strongly recommend treatment with physical therapy over no treatment with physical therapy.a (Moderate to high, )
608
21. We conditionally recommend active physical therapy interventions (supervised exercise) over passive physical therapy interventions (massage, ultrasound, heat).a (Low to moderate, )
608
22. We conditionally recommend land-based physical therapy interventions over aquatic therapy interventions.a (Moderate to high, )
608

Recommendations for Adults With Stable AS

23. We conditionally recommend on-demand treatment with NSAIDs over continuous treatment with NSAIDs. (Low-quality evidence)
608
24. In adults receiving treatment with TNFi and NSAIDs, we conditionally recommend continuing treatment with TNFi alone compared to continuing both treatments. (Low to moderate, )
608
25. In adults receiving treatment with TNFi and a conventional synthetic antirheumatic drug, we conditionally recommend continuing treatment with TNFi alone over continuing both treatments. (Low to moderate, )
608
26. In adults receiving treatment with a biologic, we conditionally recommend against discontinuation of the biologic. (Low to moderate, )
608
27. In adults receiving treatment with a biologic, we conditionally recommend against tapering of the biologic dose as a standard approach. (Low to moderate, )
608
28. In adults receiving treatment with an originator TNFi, we strongly recommend continuing treatment with the originator TNFi over mandated switching to its biosimilar. (Low to moderate, )
608
29. We strongly recommend treatment with physical therapy over no treatment with physical therapy.a ( Moderate , )
608

Recommendations for Adults With Active or Stable AS

30. In adults receiving treatment with TNFi, we conditionally recommend against co-treatment with low-dose methotrexate. ( Moderate , )
608
31. We conditionally recommend advising unsupervised back exercises.a (Moderate to high, )
608
32. We conditionally recommend fall evaluation and counseling.a (Low to moderate, )
608
33. We conditionally recommend participation in formal group or individual self-management education.a (Moderate to high, )
608
34. In adults with spinal fusion or advanced spinal osteoporosis, we strongly recommend against treatment with spinal manipulation.a (Low to moderate, )
608
35. In adults with advanced hip arthritis, we strongly recommend treatment with total hip arthroplasty over no surgery.a (Low to moderate, )
608
36. In adults with severe kyphosis, we conditionally recommend against elective spinal osteotomy.a (Low to moderate, )
608

Recommendations for Adults With AS-Related Comorbidities

37. In adults with acute iritis, we strongly recommend treatment by an ophthalmologist to decrease the severity, duration, or complications of episodes.a (Low to moderate, )
608
38. In adults with recurrent iritis, we conditionally recommend prescription of topical glucocorticoids over no prescription for prompt at-home use in the event of eye symptoms to decrease the severity or duration of iritis episodes.a (Low to moderate, )
608
39. In adults with recurrent iritis, we conditionally recommend treatment with TNFi monoclonal antibodies over treatment with other biologics. (Low-quality evidence)
608
40. In adults with inflammatory bowel disease, we do not recommend any particular NSAID as the preferred choice to decrease the risk of worsening of inflammatory bowel disease symptoms.a (Low to moderate, )
608
41. In adults with inflammatory bowel disease, we conditionally recommend treatment with TNFi monoclonal antibodies over treatment with other biologics. (Low to moderate, )
608

Disease Activity Assessment, Imaging, and Screening

42. We conditionally recommend the regular-interval use and monitoring of a validated ASa disease activity measure. (Low to moderate, )
608
43. We conditionally recommend regular-interval use and monitoring of CRP concentrations or ESR over usual care without regular CRP or ESRa monitoring. (Low to moderate, )
608
44. In adults with active AS, we conditionally recommend against using a treat-to-target strategy using a target of ASDAS <1.3 (or 2.1) over a treatment strategy based on physician assessment. ( Moderate , )
608
45. We conditionally recommend screening for osteopenia/osteoporosis with DXA scan over no screening.a (Low to moderate, )
608
46. In adults with syndesmophytes or spinal fusion, we conditionally recommend screening for osteoporosis/osteopenia with DXA scan of the spine as well as the hips, compared to DXA scan solely of the hip or other non-spine sites.a (Low to moderate, )
608
47. We strongly recommend against screening for cardiac conduction defects with electrocardiograms.a (Low to moderate, )
608
48. We strongly recommend against screening for valvular heart disease with echocardiograms.a (Low to moderate, )
608
49. In adults with AS of unclear activity while on a biologic, we conditionally recommend obtaining a spinal or pelvis MRI to assess activity. (Low to moderate, )
608
50. In adults with stable AS, we conditionally recommend against obtaining a spinal or pelvis MRI to confirm inactivity. (Low to moderate, )
608
51. In adults with active or stable AS on any treatment, we conditionally recommend against obtaining repeat spine radiographs at a scheduled interval (e.g., every 2 years) as a standard approach. (Low to moderate, )
608
a These recommendations were from 2015 and were not reviewed in this update. The number preceding the recommendation is the recommendation number and is referenced as bracketed numbers in Figure 1.

Recommendations for the Treatment of Adults With Nonradiographic Axial SpA (Table 3)

Recommendations for Adults With Active Nonradiographic Axial SpA

52. We strongly recommend treatment with NSAIDs over no treatment with NSAIDsa. (Low to moderate, )
608
53. We conditionally recommend continuous treatment with NSAIDs over on-demand treatment with NSAIDs. (Low to moderate, )
608
54. We do not recommend any particular NSAID as the preferred choice.a (Low to moderate, )
608
55. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with sulfasalazine, methotrexate, or tofacitinib over no treatment with these medications. (Very low-quality evidence)
608
56. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we strongly recommend treatment with TNFi over no treatment with TNFi. ( High , )
608
57. We do not recommend any particular TNFi as the preferred choice. (Low to moderate, )
608
58. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi over treatment with tofacitinib. (Low to moderate, )
608
59. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with secukinumab or ixekizumab over no treatment with secukinumab or ixekizumab. (Low to moderate, )
608
60. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi over treatment with secukinumab or ixekizumab. (Low to moderate, )
608
61. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with secukinumab or ixekizumab over treatment with tofacitinib. (Low to moderate, )
608
62. In adults with active nonradiographic axial SpA despite treatment with NSAIDs and who have contraindications to TNFi, we conditionally recommend treatment with secukinumab or ixekizumab over treatment with sulfasalazine, methotrexate, or tofacitinib. (Low to moderate, )
608
63. In adults with active nonradiographic axial SpA and primary nonresponse to the first TNFi used, we conditionally recommend switching to secukinumab or ixekizumab over switching to a different TNFi. (Low to moderate, )
608
64. In adults with active nonradiographic axial SpA and secondary nonresponse to the first TNFi used, we conditionally recommend switching to a different TNFi and secondary nonresponse to the first TNFi used, we conditionally recommend switching to a different TNFi over switching to a non-TNFi biologic. (Low to moderate, )
608
65. In adults with active nonradiographic axial SpA despite treatment with the first TNFi used, we strongly recommend against switching to the biosimilar of the first TNFi. (Low to moderate, )
608
66. In adults with active nonradiographic axial SpA despite treatment with the first TNFi used, we conditionally recommend against the addition of sulfasalazine or methotrexate in favor of treatment with a different biologic. (Low to moderate, )
608
67. We strongly recommend against treatment with systemic glucocorticoids.a (Low to moderate, )
608
68. In adults with isolated active sacroiliitis despite treatment with NSAIDsa, we conditionally recommend treatment with local glucocorticoids over no treatment with local glucocorticoids. (Very low-quality evidence)
608
69. In adults with active enthesitis despite treatment with NSAIDsa, we conditionally recommend using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. Peri-tendon injections of Achilles, patellar, and quadriceps tendons should be avoided. (Low to moderate, )
608
70. In adults with active peripheral arthritis despite treatment with NSAIDsa, we conditionally recommend using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. (Low to moderate, )
608
71. We strongly recommend treatment with physical therapy over no treatment with physical therapy.a ( Moderate , )
608
72. We conditionally recommend active physical therapy interventions (supervised exercise) over passive physical therapy interventions (massage, ultrasound, heat).a (Low to moderate, )
608
73. We conditionally recommend land-based physical therapy interventions over aquatic therapy interventions.a (Low to moderate, )
608

Recommendations for Adults With Stable Nonradiographic Axial SpA

74. We conditionally recommend on-demand treatment with NSAIDs over continuous treatment with NSAIDs. (Very low-quality evidence)
608
75. In adults receiving treatment with TNFi and NSAIDs, we conditionally recommend continuing treatment with TNFi alone compared to continuing both medications. (Low to moderate, )
608
76. In adults receiving treatment with TNFi and a conventional synthetic antirheumatic drug, we conditionally recommend continuing treatment with TNFi alone over continuing treatment with both medications. (Low to moderate, )
608
77. In adults receiving treatment with a biologic, we conditionally recommend against discontinuation of the biologic. ( Moderate , )
608
78. In adults receiving treatment with a biologic, we conditionally recommend against tapering of the biologic dose as a standard approach. (Low to moderate, )
608
79. In adults receiving treatment with an originator TNFi, we strongly recommend continuation of treatment with the originator TNFi over mandated switching to its biosimilar. (Low to moderate, )
608

Recommendations for Adults With Active or Stable Nonradiographic Axial SpA

80. In adults receiving treatment with TNFi, we conditionally recommend against co-treatment with low-dose methotrexate. ( Moderate , )
608

Disease Activity Assessment and Imaging

81. We conditionally recommend the regular-interval use and monitoring of a validated ASa disease activity measure. (Low to moderate, )
608
82. We conditionally recommend regular-interval use and monitoring of the CRP concentrations or ESR over usual care without regular CRP or ESRa monitoring. (Low to moderate, )
608
83. In adults with active nonradiographic axial SpA, we conditionally recommend against using a treat-to-target strategy using a target of ASDAS <1.3 (or 2.1) over a treatment strategy based on physician assessment. (Low to moderate, )
608
84. In adults with nonradiographic axial SpA of unclear activity while on a biologic, we conditionally recommend obtaining a pelvis MRI to assess activity. (Low to moderate, )
608
85. In adults with stable nonradiographic axial SpA, we conditionally recommend against obtaining a spinal or pelvis MRI to confirm inactivity. (Low to moderate, )
608
86. In adults with active or stable nonradiographic axial SpA on any treatment, we conditionally recommend against obtaining repeat spine radiographs at a scheduled interval (e.g., every 2 years) as a standard approach. (Low to moderate, )
608
a These recommendations were from 2015 and were not reviewed in this update. The number preceding the recommendation is the recommendation number and is referenced as bracketed numbers in Figure 1.

Recommendation Grading

Overview

Title

Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

Authoring Organizations

American College of Rheumatology

Spondylitis Association of America

Publication Month/Year

August 22, 2019

Last Updated Month/Year

October 8, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).

Target Patient Population

Adult patients with ankylosing spondylitis (AS) or nonradiographic axial spondyloarthritis (SpA)

Target Provider Population

Test provider

PICO Questions

  1. In adults with active or stable AS, is continuous treatment with NSAIDs more effective than on-demand treatment with NSAIDs in improving outcomes?

  2. In adults with active or stable non-radiographic axial SpA, is continuous treatment with NSAIDs more effective than on-demand treatment with NSAIDs in improving outcomes?

  3. In adults with active AS, are certain TNFi more effective than other TNFi in improving outcomes?

  4. In adults with active AS despite treatment with NSAIDs, are TNFi more effective than no treatment with TNFi in improving outcomes?

  5. In adults with active AS despite treatment with NSAIDs, are TNFi more effective than no treatment with TNFi in improving outcomes?

  6. In adults with active non-radiographic axial SpA, are certain TNFi more effective than other TNFi in improving outcomes?

  7. In adults with active AS despite treatment with NSAIDs, are TNFi more effective than no treatment with TNFi in improving outcomes?

  8. In adults with active non-radiographic axial SpA despite treatment with NSAIDs, are TNFi more effective than no treatment with TNFi in improving outcomes?

  9. In adults with active AS despite treatment with NSAIDs, is treatment with an oral small molecule more effective than no treatment with an oral small molecule in improving outcomes?

  10. In adults with active non-radiographic axial SpA despite treatment with NSAIDs, is treatment with an oral small molecule more effective than no treatment with an oral small molecule in improving outcomes?

  11. In adults with active AS despite treatment with NSAIDs and who have contraindications to TNFi, is treatment with a non-TNFi biologic more effective than treatment with an oral small molecule in improving outcomes?

  12. In adults with active non-radiographic axial SpA despite treatment with NSAIDs and who have contraindications to TNFi, is treatment with a non-TNFi biologic more effective than treatment with an oral small molecule in improving outcomes?

  13. In adults with active AS despite treatment with the first TNFi agent used, is switching to a different TNFi more effective than adding methotrexate or sulfasalazine in improving outcomes?

  14. In adults with active non-radiographic axial SpA despite treatment with the first TNFi agent used, is switching to a different TNFi more effective than adding methotrexate or sulfasalazine in improving outcomes?

  15. In adults with active AS despite treatment with the first TNFi agent used, is switching to a different TNFi more effective than switching to a non-TNFi biologic in improving outcomes?

  16. In adults with active non-radiographic axial SpA despite treatment with the first TNFi agent used, is switching to a different TNFi more effective than switching to a non-TNFi biologic in improving outcomes?

  17. In adults with stable AS on treatment with TNFi and NSAIDs, is continuing both medications more effective than continuing treatment with TNFi alone in improving outcomes?

  18. In adults with stable non-radiographic axial SpA on treatment with TNFi and NSAIDs, is continuing both medications more effective than continuing treatment with TNFi alone in improving outcomes?

  19. In adults with stable AS on treatment with TNFi and an oral small molecule, is continuing both medications more effective than withdrawing one treatment and continuing either TNFi or the oral small molecule alone in improving outcomes?

  20. In adults with stable non-radiographic axial SpA on treatment with TNFi and an oral small molecule, is continuing both medications more effective than withdrawing one treatment and continuing either TNFi or the oral small molecule alone in improving outcomes?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Treatment, Management

Diseases/Conditions (MeSH)

D013167 - Spondylitis, Ankylosing, D025241 - Spondylarthritis

Keywords

ankylosing spondylitis, axial spondyloarthritis

Source Citation

 

Ward, M.M., Deodhar, A., Gensler, L.S., Dubreuil, M., Yu, D., Khan, M.A., Haroon, N., Borenstein, D., Wang, R., Biehl, A., Fang, M.A., Louie, G., Majithia, V., Ng, B., Bigham, R., Pianin, M., Shah, A.A., Sullivan, N., Turgunbaev, M., Oristaglio, J., Turner, A., Maksymowych, W.P. and Caplan, L. (2019), 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. Arthritis Care Res, 71: 1285-1299. doi:10.1002/acr.24025

Supplemental Methodology Resources

Data Supplement