Draft ACR guidelines for axial spondyloarthritis (SpA)were presented this afternoon by Drs. Lion Caplan and Michael Ward. These guidelines address pharmacological therapy, iritis, IBD, preventative care, rehabilitation, surgery and disease monitoring.
In active ankylosing spondylitis (AS), NSAIDs are strongly recommended as first-line therapy, with no preference for which drug is used. Physiotherapy is also strongly recommended. If a patient fails NSAID therapy, TNF inhibitors (TNFi) are strongly recommended, with no preference for which agent is used, unless there is concomitant IBD (monoclonals) and recurrent iritis (infliximab or adalimumab). If TNFi are contraindicated, the guidelines conditionally recommend against slow-acting antirheumatic drugs (SAARDs), but their use may be considered if there is peripheral joint disease. The guidelines conditionally recommend against non-TNFi biologics. If a patient fails TNFi, a second TNFi is conditionally recommended. If there is active isolated sacroiliitis, peripheral arthritis or enthesitis, glucocorticoid injections may be considered. The guidelines strongly recommend against systemic glucocorticoids. Monitoring disease activity by measuring markers of inflammation is recommended, and fall prevention and unsupervised exercises are endorsed.
For stable AS, NSAIDs are strongly recommended, with conditional recommendations for on-demand use. Physiotherapy is also strongly recommended. The guidelines conditionally recommend against combining NSAIDs and TNFi or SAARD and TNFi, and favour TNFi monotherapy. Monitoring recommendations are the same as for active AS.
In active non-radiographic axial SpA, the guidelines are the same as for axial AS, with the exception of the level of recommendation for TNFi being downgraded to a conditional recommendation. In stable non-radiographic axial SpA, the guidelines are the same as for stable AS.
The presenters emphasized that these are draft guidelines that have not yet been vetted by the ACR.