What are the ASAS-EULAR treatment guidelines for axial spondyloarthritis (axSpA)?

Updated: Feb 02, 2021
  • Author: Lawrence H Brent, MD; Chief Editor: Herbert S Diamond, MD  more...
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Joint guidelines on axial SpA (axSpA) issued by the Assessment of SpondyloArthritis international Society (ASAS) and the European League Against Rheumatism (EULAR) update and aggregate previous ASAS-EULAR guidelines on AS and ASAS guidelines on management of axSpA with TNFi into a single set of recommendations. [99]

The ASAS-EULAR guidelines begin with the following five overarching principles:

  1. AxSpA is a potentially severe disease with diverse manifestations, usually requiring multidisciplinary management coordinated by the rheumatologist.
  2. The primary goal of treating the patient with axSpA is to maximize long-term health-related quality of life through control of symptoms and inflammation, prevention of progressive structural damage, and preservation/normalization of function and social participation.
  3. The optimal management of patients with axSpA requires a combination of non-pharmacological and pharmacological treatment modalities.
  4. Treatment of axSpA should aim at the best care and must be based on a shared decision between the patient and the rheumatologist.
  5. AxSpA incurs high individual, medical, and societal costs, all of which should be considered in its management by the treating rheumatologist.

The ASAS recommendations are as follows:

  • The treatment of patients with axSpA should be individualized according to the current signs and symptoms of the disease (axial, peripheral, extra-articular manifestations) and the patient characteristics, including comorbidities and psychosocial factors.
  • Disease monitoring of patients with axSpA should include patient-reported outcomes, clinical findings, laboratory tests and imaging, all with the appropriate instruments and relevant to the clinical presentation. The frequency of monitoring should be decided on an individual basis, depending on symptoms, severity and treatment.
  • Treatment should be guided according to a predefined treatment target.
  • Patients should be educated about axSpA and encouraged to exercise on a regular basis and stop smoking; physical therapy should be considered.
  • Patients suffering from pain and stiffness should use an NSAID as first-line drug treatment up to the maximum dose, taking risks and benefits into account. For patients who respond well to NSAIDs and whose symptoms recur after stopping the NSAID or reducing the dose, continuous use is advised.
  • Analgesics, such as acetaminophen and opioid-(like) drugs, might be considered for residual pain after previously recommended treatments have failed, are contraindicated, and/or are poorly tolerated.
  • Glucocorticoid injections directed to the local site of musculoskeletal inflammation may be considered. Patients with axial disease should not receive long-term treatment with systemic glucocorticoids.
  • Patients with purely axial disease should normally not be treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs); sulfasalazine may be considered in patients with peripheral arthritis.
  • Biologic DMARDs (bDMARDs) should be considered in patients with persistently high disease activity despite conventional treatments; current practice is to start with TNFi therapy.
  • If TNFi therapy fails, switching to another TNFi or an anti–interleukin-17 (IL-17) therapy should be considered.
  • If a patient is in sustained remission, tapering of a bDMARD can be considered.
  • Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age; spinal corrective osteotomy in specialized centers may be considered in patients with severe disabling deformity.
  • If a significant change in the course of the disease occurs, causes other than inflammation (eg, a spinal fracture) should be considered and appropriate evaluation, including imaging, should be performed.

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