New Spondyloarthritis Treatment Guidelines

Findings and Recommendations

In September of this year the American College of Rheumatology released the first ever recommendations for physicians in the US for the treatment of ankylosing spondylitis and non-radiographic axial spondyloarthritis. We announced their release in a news update, providing background on the project, and noting SAA’s and our members’ contributions.

Michael Ward, MD, the Principal Investigator on the guidelines, and the Rheumatology Network break down the key recommendations, providing a summary of the work’s main points.

“Key ACR recommendations for the treatment of ankylosing spondylitis:

- In adults with active AS, strongly recommend treatment with NSAIDs over no treatment with NSAIDs
- In adults with active AS, despite treatment with NSAIDs, strongly recommend treatment with TNFi over no TNFi
- In adults with active AS, no recommendation for a preferred TNFi, unless the patient has concomitant inflammatory bowel disease or recurrent iritis
- In adults with inflammatory bowel disease, strongly recommend treatment with TNFi monoclonal antibodies over treatment with etanercept
- In adults with active AS, strongly recommend against treatment with systemic glucocorticoids
- In adults with active AS, strongly recommend physical therapy over no physical therapy
- In adults with AS and advanced hip arthritis, strongly recommend total hip arthroplasty over no surgery
- In adults with active non-radiographic axial SpA despite treatment with NSAIDs, conditionally recommend treatment with TNFi over no treatment with TNFi

In addition, the new recommendations conditionally call for continuous treatment with NSAIDs over on-demand treatment with NSAIDs for active ankylosing spondylitis. Treatment with slow-acting anti-rheumatic drugs (SAARDs)* are not recommended unless the patient has contraindications to TNF inhibitors, in which case SAARDs are conditionally preferred over a non-TNFi biologic agent.

Though the authors also considered evidence for the treatment of non-radiographic axial spondyloarthritis, this relatively new condition has yet to be fully researched. Five controlled trials of adalimumab, certolizumab, etanercept and infliximab provided moderate-quality evidence for the treatment with TNF inhibitors over a placebo. Patients should be engaged in the decision to try these medications, Ward and his colleagues wrote. The remainder of the guidelines on non-radiographic axial spondyloarthritis were based on research on ankylosing spondylitis and thus were identical to the ankylosing spondylitis recommendations.”

*SAARDs – slow-acting anti-rheumatic drugs, are also referred to as DMARDs (disease-modifying anti-rheumatic drugs), and include Methotrexate and Sulphasalazine, among others.