First Guideline on Ankylosing Spondylitis Issued by ACR

Janis C. Kelly

October 06, 2015

Clinicians treating patients with either ankylosing spondylitis (AS) or nonradiographic axial spondyloarthritis (SpA) can now base treatment decisions on new, evidence-based recommendations from the American College of Rheumatology (ACR). The ACR guideline was developed with the Spondylitis Association of America and the Spondyloarthritis Research and Treatment Network and was simultaneously published online in Arthritis & Rheumatology and Arthritis Care & Research .

Lead author Michael M. Ward, MD, MPH, senior investigator in the Intramural Research Program, National Institute for Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, told Medscape Medical News, "These recommendations are the first recommendations by the ACR for the treatment of AS and nonradiographic axial SpA. Over the past 15 years, with the introduction of biological medications, there has been an expansion of treatment options for these conditions. With this come questions on how to integrate these new medications into previously established treatment practices, including, for example, when to switch to a different class of medications, or whether to stop a medication in patients who are doing well and are receiving combined treatment with medications in different classes; for example, an [nonsteroidal anti-inflammatory drug (NSAID)] and [a tumor necrosis factor inhibitor (TNFi)], or a slow-acting antirheumatic medication and a [TNFi]."

No Specific NSAID Preferred

The ACR guideline summarized recommendations for both pharmacologic and nonpharmacologic treatments, including rehabilitation, management of patients with comorbid conditions, surgery, and patient monitoring.

Key recommendations include:

  • NSAIDS for adults with active AS;

  • TNFis for adults with active AS despite NSAID treatment;

  • no specific TNFi preferred for adults with active AS, except for infliximab or adalimumab, rather than etanercept for adults with AS and inflammatory bowel disease;

  • no systemic glucocorticoids for adults with active AS;

  • physical therapy for adults with active AS;

  • total hip arthroplasty for adults with AS and advanced hip arthritis; and

  • TNFi for adults with active nonradiographic axial SpA despite treatment with NSAIDs.

Dr Ward said, "I do not think there were any surprises in the results, except perhaps the data on whether or not any particular NSAID was more effective and better tolerated than other NSAIDs, and therefore should be the preferred NSAID. The conventional teaching is that indomethacin is generally more effective for symptom control in AS than other NSAIDs, but the available data suggested that no particular NSAID was more effective, and our conditional recommendation was that there was no preferred NSAID for use in these conditions. This may require more study. Many of the treatment questions we considered had limited data, which points to the need for much more research on these topics."

The guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (or GRADE) approach, which rates both the quality of available evidence and the strength of recommendations made. Recommendations were classified as strongly for, conditionally for, conditionally against, or strongly against.

Key Problem Remains Underdiagnosis of SpA

Joel D. Taurog, MD, William M. and Gay Burnett Professorship for Arthritis Research, University of Texas Southwestern Medical School, Dallas, who was not involved in developing the guideline, told Medscape Medical News, "These guidelines from the ACR committee are an important new resource for clinicians caring for patients with axial [SpA]. The specific recommendations are in substantial agreement with the recommendations put forth by the Europeans in 2010, but with appropriately more emphasis on nonradiographic axial [SpA]."

Dr Taurog said that the focus on NSAIDs, TNFi, and physical therapy reflects the lack of established advances in specific treatment for SpA in more than a decade. However, he emphasized that the unmet need for early and accurate diagnosis of axial SpA is greater than the unmet need for appropriate treatment of diagnosed cases.

"The providers who first encounter patients with axial symptoms are rarely rheumatologists, and educating these nonrheumatologist providers on the nature of [SpA] and the need for rheumatologic referral is a major challenge for our subspecialty," Dr Taurog said.

Possible Risk for Overtreating Nonradiographic Axial SpA?

Nortin M. Hadler, MD, emeritus professor of medicine and microbiology/immunology, University of North Carolina, Chapel Hill, who was not involved in developing the guideline, told Medscape Medical News that some caution might be in order with regard to treating nonradiographic axial SpA.

Dr. Hadler warned, "For most patients, 'nonradiographic axial [SpA]' is purely a clinical diagnosis, which is jargon for a supposition that grows out of the patient–rheumatologist dialogue. The recommendation is to approach these patients as if they might have early spondylitis, following the same recommendations, but with far less certainty because of the tentative results of trials of biologic therapy in this population. However, most patients who enter into these trials are chosen because rheumatologists who have a special interest in the disease consider them to have 'nonradiographic axial SpA.' When we try to parse the patient–rheumatologist dialogue for diagnostic clues, none have emerged that are reliable. Most patients who have axial symptoms that might suggest an inflammatory pathogenesis do not have and will not develop ankylosing spondylitis. Hence, treating such patients with biologicals offers some placebo benefit, with all the attendant risks. I am uncomfortable with the fact that 'the panel relied on the AS literature as the basis for most recommendations for patients with putative non-radiographic axial SpA.' "

Instead, Dr Hadler advised clinicians to consult the literature on chronic regional back pain, which he described as "replete with examples of iatrogenicity and medicalization [but] moving more toward an understanding of enhancing [the patient's] coping skills."

Dr Ward has disclosed no relevant financial relationships. One or more of the authors reported receiving consulting fees, speaking fees, honoraria, researcher support, licensing fees and royalties, or other support from one or more of the following companies: Abbott, AbbVie, Allergan, Amgen, Array Biopharma, Augurex, Bristol-Myers Squibb, Celgene, Cipher, Clinical Care Options, Elan, Ethicon, Genentech, Genelabs, GlaxoSmithKline, Human Genome Sciences, IDEC, Iroko, Isis, Janssen, Janssen/Johnson & Johnson/Centocor/Ortho Biotech Products, Johnson & Johnson, La Jolla Pharma, Lux Biosciences, MedImmune, Medtronic, Novartis, Pfizer, Pharmacia, Proctor & Gamble, Q-Med AB, Regeneron, Sanofi, Santen, Teva, UCB, Xoma. Dr Hadler and Dr Taurog have disclosed no relevant financial relationships. Dr Taurog and Dr Hadler both serve on the Spondylitis Association of America Medical & Scientific Advisory Board.

Arthritis Rheum. Published online September 24, 2015. Abstract

Arthritis Care Res. Published online September 24, 2015. Abstract

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