ATLANTA - Today, the American College of Rheumatology (ACR), in partnership with the Spondylitis Association of America (SAA) and the Spondyloarthritis Research and Treatment Network (SPARTAN), released the 2019 Update of the Recommendations for the Treatment of Ankylosing Spondylitis (AS) and Nonradiographic Axial Spondyloarthritis (nr-axSpA). The guideline includes 86 recommendations that 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 comorbidities; and disease activity assessment, imaging, and screening.
"SAA is proud to be a co-sponsor of these updated guidelines. SAA is committed to expanding treatment options and ensuring that both spondyloarthritis patients and the medical practitioners that are entrusted with their care have the best resources to aid in their decision-making," said Cassie Shafer, chief executive officer of the SAA.
Axial SpA, which is comprised of AS and nr-axSpA, is the main form of chronic inflammatory arthritis affecting the axial skeleton. This condition is characterized by back and hip pain, peripheral joint pain, and fatigue, all of which can vary in severity. According to the SAA, as much as 1 percent of the adult United States population may have axial SpA. This means that as many as 2.7 million adults may be affected by the disease.
The ACR's previous guideline, published in 2015, provided recommendations for pharmacological treatments, management of selected comorbidities, disease monitoring, and preventive care. The 2019 update builds on these recommendations by adding information on new medications, managing biologic and biosimilars usage in patients, and best practices for utilizing imaging (MRI and radiographs).
"Based on the literature, we felt it was important to address topics such as sequencing biologics for patients with active AS despite NSAID usage, whether to taper or discontinue biologics in the setting of remission, and clearer guidelines on when to obtain images - particularly in instances when results would likely lead to a change in treatment," said Michael Ward, MD, MPH, researcher at the National Institute of Arthritis and Musculoskeletal and Skin Diseases and principal investigator of the guideline. "We hope this new information will help get patients on an effective treatment faster and ultimately improve patients' health status and quality of life."
To update the guideline, a team of experts conducted a systematic literature review for 20 clinical questions on pharmacological treatment addressed in the 2015 guidelines along with 26 new questions on pharmacological treatment, treat-to-target strategy, and the use of imaging. The results of this review were then discussed by a separate voting panel and crafted into recommendations that were labeled conditional or strong based on the evidence available. A few of the recommendations from the guideline include:
- A strong recommendation to treat adults with active AS despite treatment with NSAIDs with a TNFi (no preferred choice) over no treatment with a TNFi.
- A conditional recommendation to treat with a TNFi over treatment with secukinumab, ixekizumab or tofacitinib, and a conditional recommendation to treat with seukinumab or ixekizumab over tofacitinib.
- A strong recommendation to continue treatment with the originator biologic over mandated switching to its biosimilar for adults with stable AS.
- A conditional recommendation against obtaining repeat spine radiographs at a scheduled interval as a standard approach for adults with active or stable nr-axSpA on any treatment.
"These guidelines update those from four years ago by consolidating the expert thought around the use of the newest therapeutic agents and modifying a number of recommendations from the 2015 guideline to reflect recent evidence. They provide patients and the medical community with clear recommendations for spondyloarthritis management using a rigorous approach, and SPARTAN is proud to endorse them," said Dr. Liron Caplan, chair of SPARTAN.
ACR guidelines are currently developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which creates rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations. Due to limited data in some areas, the quality of evidence was most often low, very low or occasionally moderate. This led to nearly all recommendations being conditional, with only a few strong recommendations in cases in which there was sufficient evidence.
The updated and expanded recommendations, supporting PICO questions and evidence report are available on the ACR website.
About the American College of Rheumatology
The American College of Rheumatology is an international medical society representing over 7,700 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care.
Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases. For more information, visit http://www.rheumatology.org.
About the Spondylitis Association of America
Since our founding in 1983, the Spondylitis Association of America has been the leading national nonprofit that provides educational resources, connections, and the critical emotional support that people living with spondylitis need. SAA is committed to increasing awareness of spondylitis, providing information and support to patients and their families, and funding research to ultimately uncover a cure for the disease.
SAA has a wealth of information, educational materials, and resources for medical practitioners, the newly diagnosed, those who are seeking a proper diagnosis, and those who have already been diagnosed and living with the disease. For more information, visit http://www.spondylitis.org.
About the Spondyloarthritis Research and Treatment Network
The Spondyloarthritis Research and Treatment Network (SPARTAN) is comprised of health care professionals in North America who are dedicated to research, awareness and treatment of spondyloarthritis. This is achieved through scientific meetings, projects, seminars and grants. SPARTAN's vision is of a world free of spondyloarthritis through leadership in research and education. For more information, visit http://www.spartangroup.org.