ACR Updates Treatment Guideline for Ankylosing Spondylitis, Nonradiographic Axial Spondyloarthritis
The American College of Rheumatology (ACR), in partnership with the Spondylitis Association of America (SAA) and the Spondyloarthritis Research and Treatment Network (SPARTAN), released updated recommendations for the treatment of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA).
The guideline includes 86 recommendations that provide updated and new guidance for the management of patients with AS and nr-axSpA in the areas of pharmacologic and nonpharmacologic treatment options; AS-related comorbidities; and disease activity assessment, imaging, and screening.
“Based on the literature, we felt it was important to address topics such as sequencing biologics for patients with active AS despite NSAID usage, whether to taper or discontinue biologics in the setting of remission, and clearer guidelines on when to obtain images -- particularly in instances when results would likely lead to a change in treatment,” said Michael Ward, MD, National Institute of Arthritis and Musculoskeletal and Skin Diseases, part of the National Institutes of Health, Bethesda, Maryland. “We hope this new information will help get patients on an effective treatment faster and ultimately improve patients’ health status and quality of life.”
To update the guideline, a team of experts conducted a systematic literature review of 20 clinical questions on pharmacological treatment addressed in the 2015 guidelines along with 26 new questions on pharmacological treatment, treat-to-target strategy, and the use of imaging. The results of the review were then discussed by a separate voting panel and crafted into recommendations that were labelled conditional or strong based on the evidence available. A few of the recommendations from the guideline include:
● Treat adults with active AS despite treatment with NSAIDs with a tumour necrosis factor inhibitor (TNFi) over no treatment with a TNFi (strong recommendation).
● Conditional recommendations to treat with a TNFi over treatment with secukinumab, ixekizumab or tofacitinib, and a conditional recommendation to treat with secukinumab or ixekizumab over tofacitinib.
● Continue treatment with the originator biologic over mandated switching to its biosimilar for adults with stable AS (strong recommendation).
● Conditional recommendation against obtaining repeat spine radiographs at a scheduled interval as a standard approach for adults with active or stable nr-axSpA on any treatment.
ACR guidelines are currently developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which creates rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations. Due to limited data in some areas, the quality of evidence was most often low, very low or occasionally moderate. This led to nearly all recommendations being conditional, with only a few strong recommendations in cases in which there was sufficient evidence.
SOURCE: American College of Rheumatology