Revised Axial Spondyloarthritis Management Recommendations

Revised recommendations for the management of patients with axial spondyloarthritis (axSpA) have been issued jointly by the Assessment of SpondyloArthritis International Society (ASAS) and the European League Against Rheumatism (EULAR). The recommendations were published in Annals of the Rheumatic Diseases.¹

Intended to provide guidance on the non-pharmacologic and pharmacologic management in patients with axSpA, the document is an aggregation of ASAS/EULAR management recommendations in ankylosing spondylitis (AS) and ASAS recommendations in the management of axSpA with tumor necrosis factor-alpha inhibitors (TNFi). 

In an email interview with Rheumatology Advisor, lead investigator Désirée van der Heijde MD, PhD, of Leiden University Medical Center, Leiden, the Netherlands, stated, “This is the first time that the recommendations are for the entire group of patients with axSpA, while in the previous recommendations the focus was on ankylosing spondylitis with limited attention to non-radiographic axSpA. Now it is considered as one set of recommendations for the entire spectrum of the disease, and these recommendations are now integrated into the previous management recommendations and the use of TNF-blockers.” 

Although it has been controversial whether or not radiographic axSpA and non-radiographic axSpA (nr-axSpA) are separate clinical entities or manifestations of the same disease, the revised ASAS/EULAR recommendations reflect the current prevailing opinion that axSpA encompasses 1 disease spectrum that includes both types of axSpA.

Key recommendations include: 

• An individualized approach to treatment and monitoring
• The use of non-pharmacologic management, including exercise, smoking cessation, and physical therapy
• The use of nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy
• Consideration of the use of biological disease-modifying antirheumatic drugs (bDMARDs) in patients with persistently high disease activity despite conventional treatments, with a preference for TNFi therapy over interleukin-17 inhibitors (IL-17i)
• Consideration of a switch to another TNFi or IL-17i in the case of a lack of response to treatment with TNFi therapy
• Consideration of tapering bDMARDs in patients in sustained remission
• The endorsement of the AS Disease Activity Score (ASDAS) as a relevant measure to assess disease activity
• Indications for total hip arthroplasty and spinal corrective osteotomy

Although stating that the 2016 recommendations from the American College of Rheumatology (ACR) in the treatment of AS and non-radiographic axSpA are similar, the investigators noted some distinctions in the ASAS/EULAR recommendations, including: “treatment according to a target, the explicit conditions in which a bDMARD should be started, tapering of a bDMARD, the use of IL-17i, taking aspects of costs into account, and treating axSpA as 1 continuum of the disease.”

The next iteration of the recommendations will be issued when sufficient new data on present and emerging treatments becomes available.

Disclosures

Dr van der Heijde received consulting fees from AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boeringer Ingelheim, Celgene, Daiichi, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis, and UCB and is Director of Imaging Rheumatology BV. Dr Landewé received consulting fees from AbbVie, Ablynx, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Janssen, Galapagos, GlaxoSmithKline, Novartis, Novo-Nordisk, Merck, Pfizer, Rhoche, Schering-Plough, TiGenix, and UCB and is Director of Rheumatology Consultancy BV. Dr Baraliakos received consulting fees and research grants from AbbVie, Bristol-Myers Squibb, Celgene, Janssen, Novartis, Pfizer, Roche, MSD, and UCB. Dr Van den Bosch received consulting and/or speaker fees from AbbVie, BMS, Celgene, Eli-Lilly, Janssen, Merck, Novartis, Pfizer, and UCB. Dr Ciurea received consulting fees from AbbVie, Celgene, Eli-Lilly, Janssen-Cilag, Merck Sharp & Dohme, Novartis, Pfizer, and UCB. Dr Dougados received consulting fees from AbbVie, BMS, Boeringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis, and UCB. Dr van Gaalen received consulting fees from Pfizer, MSD, AbbVie, and Novartis. Dr Géher received consulting fees from AbbVie and Roche. Dr van der Horst-Bruinsma received consulting fees from AbbVie, UCB, and MSD and received unrestricted grants for investigator-initiated studies from MSD, Pfizer, and AbbVie. Dr Inman received consulting fees from Amgen, Janssen, AbbVie, and Novartis. Dr Kiltz received consultancy fees as well as grant and research support from AbbVie, Chugai, MSD, Novartis, Pfizer, Roche, and UCB. Dr Kvien received consulting fees from AbbVie, Biogen, BMS, Boehringer Ingelheim, Celltrion, Eli-Lilly, Epirus, Janssen, Merck-Serono, MSD, Mundipharma, Novartis, Oktal, Orion Pharma, Hospira/Pfizer, Roche, Sandoz, and UCB Pharma. Dr Machado received speaker/consulting fees from AbbVie, Centocor, Janssen, MSD, Novartis, and Pfizer. Dr Marzo-Ortega received consulting fees from AbbVie, Celgene, Janssen, MSD, Novartis, Pfizer, and UCB and grants from Janssen and Pfizer. Dr Molto received consulting fees and/or grants from AbbVie, Merck Pfizer, and UCB. Dr Navarro-Compàn received consulting fees from AbbVie, BMS, Novartis, Pfizer, Roche, and UCB. Dr Ozgocmen received consulting fees, speaking fees and/or honoraria from AbbVie, Pfizer, UCB, Merck Sharp & Dohme, and Novartis. Dr Pimentel-Santos received consulting fees from AbbVie, Celgene, Janssen, Novartis, Pfizer, Roche, Merck Sharp & Dohme, UCB, and Biogen. Dr Reveille received consulting fees from Janssen and is a participant in clinical trials of Janssen and Eli-Lilly. Dr Rudwaleit received consulting or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Chugai, Janssen, Novartis, Merck, Pfizer, Roche, and UCB. Dr Sieper received consulting fees from AbbVie, Boeringer Ingelheim, Eli-Lilly, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, and UCB. Dr Sampaio-Barros received consulting fees from AbbVie, Janssen, Novartis, Pfizer, Roche, and UCB. Dr Braun received research grants, honoraria, speaker fees, and consultancy payments from AbbVie (Abbott), Amgen, Biogen, Boehringer Ingelheim, BMS, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Epirus, Hospira, Janssen, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB.

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Reference

1. Heijde D van der, Ramiro S, Landewé R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis [published online January 13, 2017]. Ann Rheum Dis. doi:10.1136/annrheumdis-2016-210770.

This article originally appeared on Rheumatology Advisor