EULAR/ASAS: Axial SpA management should pursue predefined treatment goal
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Axial spondyloarthritis management should be guided by a predetermined treatment target, according to new recommendations published by the Assessment of Spondyloarthritis international Society and EULAR.
“Evidence on the efficacy of the different drugs on the [extra-musculoskeletal manifestations (EMMs)] has been accumulating, with data available in patients with pure [axial SpA (axSpA)] or in other populations such as patients with psoriasis, psoriatic arthritis (PsA) or IBD,” Sofia Ramiro, MD, PhD, of the Leiden University Medical Center, in the Netherlands, and colleagues wrote in the Annals of the Rheumatic Diseases. “The current work represents the 2022 update of the ASAS-EULAR recommendations for the management of axSpA guided by the newly available evidence since the 2016 update.”
To update the ASAS-EULAR recommendations for the management of axial SpA, the groups established a joint steering committee and task force members were invited to participate. Research questions were defined to direct the systematic literature review, which was then performed by two fellows. The first review focused on non-pharmacological, non-biological interventions. The second investigated biological disease-modifying antirheumatic drugs. The reviews included data published from the end of the last review, which was performed in 2016, through Jan. 1, 2022. The 2016 recommendations were used as a basis to begin the discussion surrounding new potential guidelines.
The task force conducted an online meeting in February, during which the reviews were presented and discussed. Review results, expert opinions, safety, efficacy and cost-related concerns were considered when crafting the principles and guidelines. Recommendations were edited in a live fashion, followed by anonymous voting. Consensus was reached if 75% or more members agreed with the decision to include a recommendation. Levels of agreement were determined after the meeting by way of an online survey.
The new guidelines include five overarching principles and 15 recommendations. The overarching principles state that axial SpA demonstrates diverse manifestations and requires multidisciplinary care. Additionally, they define primary goal of therapy as maintaining long-term, health-related quality of life, and advise that optimal management strategies include pharmacological and non-pharmacological interventions based on joint decision-making. Finally, social, individual and financial costs should be considered when deciding a course of treatment, according to the principles.
Out of the 15 recommendations, eight were unchanged from previous recommendation publications. Three received minor updates, two received significant updates and two are new. The recommendations include:
- Treatment should be individualized according to current disease symptoms and signs.
- Disease monitoring should include patient-reported outcomes as well as clinical findings, laboratory tests and imaging.
- Therapy should be guided in pursuit of a predetermined treatment goal.
- Patients should be encouraged to exercise, while considering the option of physiotherapy.
- Patients experiencing pain should use NSAIDs up to the maximum dose.
- Analgesics should be considered after NSAID therapy fails for pain management.
- Glucocorticoid injections should be considered in areas of musculoskeletal inflammation, but should not be used long-term.
- Purely axial disease should not be treated with conventional synthetic DMARDs.
- TNF inhibitors, interleukin-17 inhibitors, or Janus kinase inhibitors can be considered in patients with maintained high disease activity.
- In patients with a history of uveitis or inflammatory bowel disorder, monoclonal antibodies against tumor necrosis factor may be considered.
Other recommendations state that if a patient fails to respond to therapy, providers should reconsider the diagnosis and potential comorbidities, and when a biologic or traditional synthetic DMARD fails, providers should consider switching to a drug in the same class.
Additionally, providers may taper DMARDs in patients experiencing sustained remission, and consider arthroplasty for those with radiographic evidence of structural damage and refractory pain. Lastly, causes besides inflammation should be considered when there is a significant shift in disease course.
“The 2022 update of the ASAS-EULAR recommendations provides health care professionals taking care of patients with axSpA, patients and other relevant stakeholders with the most up-to-date evidence and expert insights in the management of patients with axSpA,” Ramiro and colleagues wrote. “The next update is expected to be undertaken when sufficient new evidence has become available on existing or new treatment options.”
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