The availability of new medications to treat axial spondyloarthritis (axSpA), including medications recently approved by the U.S. Food and Drug Administration to treat ankylosing spondylitis (AS)—secukinumab and ixekizumab—as well as new evidence on tapering and discontinuing biologics, magnetic resonance imaging (MRI) and radiograph imaging are the driving forces behind the release of a revised guideline for ankylosing spondylitis. The new guideline, “2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis [nr-axSpA],” is now available online.1
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AxSpA (including both AS and nr-axSpA) is the main form of chronic inflammatory arthritis affecting the axial skeleton. As many as 2.7 million adults may be affected by the disease, which is characterized by back and hip pain, peripheral joint pain and fatigue.2
The 2019 guideline includes 86 recommendations presented by the ACR, in partnership with the Spondylitis Association of America (SAA) and the Spondyloarthritis Research and Treatment Network (SPARTAN), to provide updated and new guidance for the management of patients with AS and nr-axSpA in the areas of pharmacologic and non-pharmacologic treatment options, AS-related co-morbidities, disease activity assessment, imaging and screening.
“New medications to treat axial spondyloarthritis, most notably interleukin 17A (IL-17A) inhibitors, secukinumab and ixekizumab, are now supported by large, published clinical trials that demonstrated efficacy in AS, so we thought it was important to update the recommendations to accommodate this new information,” says Michael Ward, MD, lead investigator of the guideline update.3,4
Early studies on tofacitinib and an expanding number of tumor necrosis factor inhibitor (TNFi) biosimilars, as well as recommendations on some other topics, such as imaging, were also considered in the update.
Guideline Updates at a Glance
To revise the guideline, Dr. Ward and the panel of co-authors updated the systematic literature review for 20 clinical questions on pharmacologic treatment addressed in the 2015 guideline and conducted a new literature review for 26 new questions on pharmacologic treatment, treat-to-target strategies and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, TNFi biosimilars and biologic tapering and discontinuation, among other factors. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology was used to assess the quality of evidence and formulate recommendations. At least 70% agreement among the guideline voting panel was required for a recommendation to be included in the guideline.
The 2019 recommendations for AS and nr-axSpA are similar to the earlier guideline. Many of the recommendations are conditional instead of strong, driven mainly by the fact that little evidence in the literature supports the recommendation and future evidence may contradict it. Among the recommendations: