Treatment recommendations for the management of axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a type of arthritis that affects the joints in the axial skeleton (chest, spine and pelvis). People with axSpA often have back pain before the age of 45. The pain is chronic and can be severe and debilitating. Other body systems may also be affected. For example, people may experience eye inflammation or diarrhea.1The Spondyloarthritis Research Consortium of Canada (SPARCC) and the Canadian Rheumatology Association (CRA) have released new treatment recommendations for the management of patients with axial spondyloarthritis (axSpA), updating the previous recommendations published in 2014. A “living” model is being used for the new treatment recommendations, enabling them to be updated regularly as new data and evidence emerge.2The document offers 56 recommendations for the management of patients with active axSpA, stable axSpA, active or stable axSpA, comorbidities, and for assessment, screening and imaging. Recommendations are also included for principles of management, disease monitoring and ethical considerations.Key recommendations for the management of active axSpA are highlighted below:The goal of treatment is remission/inactive disease. When remission/inactive disease is not possible, the goal is low/minimal disease activity and control of symptoms, prevention of damage and improvement in quality of life.Optimal management includes nonpharmacologic and pharmacologic treatments, as well as patient education.No formal recommendations were made for treatment with conventional disease-modifying drugs (DMARDs, e.g., methotrexate or sulfasalazine) since it is well established that they are not effective in axial disease.Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) is strongly recommended over no treatment with NSAIDs. Continuous treatment with NSAIDs is conditionally recommended over on-demand treatment with NSAIDs.Any available NSAID is conditionally recommended over the use of a particular NSAID as a preferred choice.The CRA strongly recommends against treatment with systemic glucocorticoids.When use of NSAIDs is insufficient, treatment with a tumour necrosis factor inhibitor (TNFi, e.g., adalamumab) is strongly recommended over no treatment with a TNFi.Any available TNFi is conditionally recommend for musculoskeletal manifestations. Limited direct evidence does not suggest the superiority of one TNFi over another.When use of NSAIDs is insufficient, treatment with an interleukin17 inhibitor (IL-17i) is strongly recommended over no treatment. IL-17is are effective in axSpA and have a reassuring safety profile.The CRA conditionally does not recommend treatment with an IL-17i over treatment with a TNFi or vice versa.Treatment with a Janus kinase inhibitor (JAKi, e.g., upadacitinib, tofacitinib) is conditionally recommend over no treatment with a JAKi. The CRA conditionally recommends against treatment with a JAKi over treatment with a TNFi. There is no direct evidence suggesting efficacy of one agent over another; however, head-to-head trials in other patient populations demonstrate increased risks with tofacitinib.The CRA conditionally recommends against treatment with a JAKi over treatment with an interleukin-17 inhibitor (IL-17i, e.g., secukinumab). Both are effective, but IL-17is appear to be safer.In patients with contraindications to TNFis, either IL-17is or JAKis are conditionally recommended. IL-17is appear safer, but in certain clinical situations (e.g., presence of inflammatory bowel disease), the use of a JAKi would probably be preferred over an IL-17i.In patients with contraindications to TNFis, the CRA recommends against use of IL-6 inhibitors and apremilast.When a TNFi is ineffective, the CRA conditionally recommends switching to a different TNFi rather than adding a conventional synthetic DMARD (e.g., methotrexate, sulfasalazine).When treatment with a TNFi is ineffective, the CRA conditionally recommends the use of JAKi over no treatment.The CRA aims to update these treatment recommendations annually. Treatment recommendations for juvenile spondyloarthritis are currently underway. In addition, the CRA plans to develop recommendations for the treatment of peripheral spondyloarthritis in adults and children. References:1. Cleveland Clinic. Axial spondyloarthritis. (accessed July 9, 2024).2. Rohekar S, Pardo JP, Mirza R, et al. Canadian Rheumatology Association/Spondyloarthritis Research Consortium of Canada living treatment recommendations for the management of axial spondyloarthritis. J Rheumatol 2024; published online July 1, 2024. (accessed July 9, 2024).

Treatment recommendations for the management of axial spondyloarthritis

Register for free access or login.

Related Topics