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

Abstract

Objective To update evidence‐based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). Methods We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat‐to‐target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. Results Recommendations for AS and nonradiographic axial SpA are similar. TNFi 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 primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co‐administration of low‐dose methotrexate with TNFi is not recommended, nor is a strict treat‐to‐target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. Conclusion These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.

Unmet needs in ankylosing spondylitis patients receiving tumour necrosis factor inhibitor therapy; results from a large multinational real-world study

“…4 Results are adjusted for age, gender, BMI, smoking status, time since symptom onset and region inadequate efficacy was 11 months [26]. These findings indicate that patients may be maintained on failing therapy for significantly longer than the 12 weeks recommended by ACR/SAA/SPARTAN treatment guidelines [9]. Our analyses also demonstrate that failing TNFi therapy is associated with poorer patient-reported HRQoL, as measured by EQ-5D-3 L and SF-36, as well as negative impact on daily activities measured by WPAI.…”

“…TNFi treatment failure is an important consideration in the management of AS patients, since until recently TNFi were the only approved biologic treatment for AS. Following the recent approvals of the IL-17A antagonists secukinumab and ixekizumab, the ACR/SAA/SPARTAN recommendations include switching to either [9] as they are demonstrated effective in patients with inadequate response to TNFi, providing an option for those whose disease is not controlled by TNFi therapy [28,29]. At the time of this study, TNFi were the only biologic therapy available, therefore the real-world clinical impact of switching to a new class of biologics such as secukinumab or ixekizumab could not be assessed and represents an important area of future research.…”

“…Primary pharmacologic treatment of AS are nonsteroidal anti-inflammatory drugs, with biological Disease Modifying Anti-Rheumatic Drugs (bDMARDs) such as tumour necrosis factor inhibitors (TNFi) as a first-line bDMARD option, and the interleukin (IL)-17A inhibitors secukinumab and ixekizumab recommended for patients who have failed TNFi treatment [9]. It is not uncommon for patients with AS to experience TNFi therapeutic failure.…”

Use and Switching of Biologic Therapy in Patients with Non-Radiographic Axial Spondyloarthritis: A Patient and Provider Survey in the United States

“…NSAIDs are still considered first-line pharmacological treatment for nr-axSpA [11], however biologics may be effective for patients that do not respond to NSAIDs. Biologics are considered for treating nr-axSpA patients with objective signs of inflammation, defined as active inflammation seen on MRI or elevated C-reactive protein (CRP) levels or patients who do not respond to NSAID therapy [6]. Currently, certolizumab pegol is the only FDA-approved biologic for nr-axSpA in the US.…”

“…Patients with AS and nr-axSpA have comparable clinical characteristics and burden of disease, requiring similar treatment [5]. Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered first-line therapy for patients with AS and nr-axSpA [6,7]. Traditional conventional disease-modifying antirheumatic drugs (cDMARDs) such as methotrexate and sulfasalazine are not considered effective for the treatment of axSpA [7][8][9].…”