• TNFi’s are recommended over secukinumab or ixekizumab as the first biologic to be used;
• Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with a primary nonresponse to the first TNFi;
• Secukinumab and ixekizumab are favored over tofacitinib;
• Co-administration of low-dose methotrexate with a TNFi is not recommended, nor is a strict treat-to-target strategy, or discontinuation or tapering of biologics as a standard approach in patients with stable disease;
• Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi’s are contraindicated; and
• For patients with unclear disease activity, spine or pelvis MRI could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended.
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Please refer to the full guideline for a complete list of recommendations—and whether they are strongly recommended, conditionally recommended, conditionally recommended against or strongly recommended against—for each condition.
Dr. Ward further explains three key guideline updates and how they will affect patient treatment.
Sequencing biologics for patients with active AS despite non-steroidal anti-inflammatory drug (NSAID) usage: For these patients, the recommendations are to first treat with a TNFi, provided there are no contraindications, Dr. Ward explains. “If there is a good response to the first TNFi, but effectiveness is lost over time, the recommendation is to treat with a different TNFi. If there is little or no response to the first TNFi, the recommendation is to treat with an IL-17 inhibitor. There is no preference for using any particular TNFi, but this is not the case if the patient has particular co-morbid conditions, such as recurrent uveitis or inflammatory bowel disease, when TNFi monoclonal antibodies should be used.”
Whether to taper or discontinue biologics in the setting of remission: For patients in sustained remission, the recommendation against tapering of biologics as a standard approach is conditional, Dr. Ward explains, noting that treatment is often needed long-term, and the evidence at present does not support that tapering after a certain amount of time in remission will not result in return of symptoms. He says that “as a standard approach” is an important qualifier, because tapering could be considered in some patients with shared decision making.
“This is why the recommendation is conditional,” he says. “The recommendation against discontinuation of biologics was also conditional, because the limited evidence suggests symptoms recur in many patients. Thus, many patients may want to stay on their medication to ensure this does not happen.”