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acr-axial-spondyloarthritis-2015-482927f926-chunk-0000 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 0 | ARTHRITIS & RHEUMATOLOGY
DOI 10.1002/ART.39298
V
C 2015, AMERICAN COLLEGE OF RHEUMATOLOGY
SPECIAL ARTICLE
American College of Rheumatology/Spondylitis Association of
America/Spondyloarthritis Research and Treatment Network 2015
Recommendations for the Treatment of Ankylosing Spondylitis
and Nonradiographic Axial Spondy... | 0 | 2,500 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0001 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 1 | Akl, MD, MPH, PhD: American University of Beirut, Beirut,
Lebanon, and McMaster University, Hamilton, Ontario, Canada;
4Andrew Lui, PT, DPT, Lianne S. Gensler, MD: University of California,
San Francisco; 5Joerg Ermann, MD: Brigham and Women’s Hospital,
Boston, Massachusetts; 6Judith A. Smith, MD, PhD: University of
W... | 2,250 | 3,750 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0002 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 2 | Objective. To provide evidence-based recommen-
dations for the treatment of patients with ankylosing
spondylitis (AS) and nonradiographic axial spondylo-
arthritis (SpA).
Methods. A core group led the development of
the recommendations, starting with the treatment ques-
tions. A literature review group conducted system... | 3,752 | 6,252 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0003 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 3 | -
shed in this family by universal involvement with sacro-
iliac joint inflammation or fusion, and more prevalent
spinal ankylosis (3); these more advanced sacroiliac
changes form the core of the modified New York criteria
for the classification of AS (4). Radiographic features
may take years to develop, which limits t... | 6,002 | 8,502 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0004 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 4 | lgene,
UCB, and Pfizer (less than $10,000 each). Dr. Maksymowych has
received consulting fees, speaking fees, and/or honoraria from Abb-
Vie, UCB, Pfizer, Amgen, Janssen, and Augurex (less than $10,000
each) and receives licensing fees and royalties from Augurex for the
14-3-3 biomarker. Mr. Clark has received consulti... | 8,252 | 10,194 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0005 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 5 | and features suggestive of SpA but who do not meet the
classification criteria for AS.
The goals of treatment of AS and nonradio-
graphic axial SpA are to reduce symptoms, maintain spi-
nal flexibility and normal posture, reduce functional
limitations, maintain work ability, and decrease disease
complications. The main... | 10,196 | 12,696 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0006 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 6 | al interest in SpA, in response to a request for
proposals from the American College of Rheumatology
(ACR) and with support from the Spondylitis Association
of America (SAA), a patient advocacy organization. The
project began in late 2012 after the ACR and SAA boards
approved the proposal, and was modified based on com... | 12,446 | 14,946 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0007 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 7 | o have no rel-
evant conflicts of interest. The principal investigator and liter-
ature review committee leader were also required to have no
relevant conflicts of interest.
Developing the PICO questions. Guidelines are most
useful when they provide specific actionable advice on choosing
between alternative approaches ... | 14,696 | 16,145 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0008 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 8 | Because therapy goals of most treatments are similar,
we developed a common outcomes framework to apply across
PICO questions. The framework included 5 major outcomes:
mortality, health status, functional status, serious adverse
events, and comorbidities (Table 1). For health status and
functional status, we used patie... | 16,147 | 18,647 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0009 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 9 | heumatology web site at http://online
library.wiley.com/doi/10.1002/art.39298/abstract.
Data abstraction and rating the quality of evidence. A
major principle of the GRADE method is to base recommen-
dations on the best available evidence identified through a sys-
tematic literature review and summarized in quantitativ... | 18,397 | 19,414 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0010 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 10 | not include standard deviations) were not included in the evi-
dence report. The review group synthesized these data to pro-
duce an effect estimate for each outcome, and assessed the
quality of the evidence based on the risk of bias, imprecision in
the estimates of effect, inconsistency among studies, indirect-
ness (... | 19,416 | 21,916 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0011 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 11 | -quality evidence and reflect a
high degree of confidence that future research will not change
the results. Strong recommendations usually involve interven-
tions sufficiently clear in their benefits and risks that almost all
informed patients would accept the recommendation. A condi-
tional recommendation is more appr... | 21,666 | 24,166 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0012 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 12 | ongly against
Most patients should not receive the
intervention
Should not be offered to patients
Should be adopted as policy
* GRADE 5 Grading of Recommendations, Assessment, Development and Evaluation.
Table 1.
Outcomes framework*
The framework included the following 5 major outcomes:
Mortality
Health status
Sympto... | 23,916 | 25,122 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0013 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 13 | purposes of these recommendations, we defined active disease
as disease causing symptoms at an unacceptably bothersome
level as reported by the patient, and judged by the examining
clinician to be due to SpA. We defined stable disease as that
which was asymptomatic or causing symptoms that were both-
ersome but at an a... | 25,124 | 27,624 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0014 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 14 | IDs and that the desir-
able consequences far outweighed undesirable conse-
quences for the large majority of patients, justifying a
strong recommendation. Although some patients have
contraindications to treatment, the panel thought there
was likely little variation among patients in preferences
for treatment with NSA... | 27,374 | 28,441 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0015 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 15 | and depression were more common in the continuous
treatment group. Despite this, the panel favored daily
NSAID treatment for the period of active AS for most
patients. The decision to use NSAIDs continuously may
vary depending on the severity and intermittency of symp-
toms, comorbidities, and patient preferences. The ... | 28,443 | 30,943 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0016 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 16 | d had a higher risk of
side effects than placebo. Although treatment with sulfasa-
lazine did not improve peripheral joint counts, small bene-
fit was seen in a composite measure of peripheral arthritis
symptoms. The other medications were tested in small
numbers of patients. Trials of methotrexate were limited
by use ... | 30,693 | 33,193 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0017 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 17 | sk of side effects differently.
The panel judged that lack of response (or intoler-
ance) to at least 2 different NSAIDs over 1 month, or
incomplete responses to at least 2 different NSAIDs
over 2 months, would be adequate trials with which to
judge NSAID responses.
Evidence to guide the choice of TNFi, based on
either... | 32,943 | 33,812 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0018 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 18 | in ASAS criteria for 20% improvement in disease activity
responses, while other clinical outcomes were not exam-
ined. The quality of evidence was judged to be moderate
and insufficient to support recommendation of the use of
one TNFi over another. However, the panel thought that
in patients with inflammatory bowel dis... | 33,814 | 36,314 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0019 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 19 |
ferent TNFi over adding a SAARD (PICO 9; very
low-quality evidence; vote 100% agreement).
We conditionally recommend treatment with a dif-
ferent TNFi over treatment with a non-TNFi bio-
logic agent (PICO 10; very low-quality evidence;
vote 90% agreement).
Evidence and rationale. This recommendation ad-
dresses TNFi f... | 36,064 | 38,564 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0020 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 20 | he case series, there were modest
improvements with treatment over 4–6 months, but the
studies had a serious risk of bias and imprecise esti-
mates of effect. The overall quality of evidence was
therefore rated as very low. The panel concluded that
there was little evidence to support long-term treatment
with systemic ... | 38,314 | 38,962 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0021 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 21 | In adults with AS and isolated active sacroiliitis despite
treatment with NSAIDs, we conditionally recommend
treatment with locally administered parenteral gluco-
corticoids over no treatment with local glucocorticoids
(PICO 13; very low-quality evidence; vote 100% agree-
ment).
Evidence and rationale. Sacroiliac joint... | 38,964 | 41,464 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0022 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 22 | y and patient preferences for
local versus systemic treatment with a SAARD or TNFi.
Similarly, no studies reported on the use of intraar-
ticular glucocorticoid injections in the treatment of active
peripheral arthritis in AS. The panel recommended this
treatment as an option, based on evidence from other rheu-
matic d... | 41,214 | 43,714 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0023 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 23 | t http://onlinelibrary.wiley.
com/doi/10.1002/art.39298/abstract). Given the absence of
strong evidence favoring aquatic interventions, the pan-
el judged that aquatic therapy should not take prece-
dence over land-based therapy. While aquatic therapy
can be used by those with access to a swimming pool or
hydrotherapy ... | 43,464 | 43,940 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0024 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 24 | B. Recommendations for the treatment of patients with
stable AS
B1. Pharmacologic treatment
In adults with stable AS, we conditionally recommend
on-demand treatment with NSAIDs over continuous
treatment with NSAIDs (PICO 1; very low-quality evi-
dence; vote 100% agreement).
Evidence
and
rationale. This recommendation
d... | 43,942 | 46,442 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0025 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 25 | r
NSAIDs or SAARDs in this setting has uncertain but
likely little benefit, but entails risk of gastrointestinal,
renal, cardiac, and hematologic toxicity (23,24).
It is important to note that the recommendation
regarding SAARDs does not apply to the question of
using low-dose methotrexate with TNFi treatment to
decrea... | 46,192 | 48,429 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0026 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 26 | symptoms as a guide to treatment. Monitoring was not
thought necessary at every clinic visit, and could be omit-
ted in patients who were clinically stable for some time.
In adults with active or stable AS, we conditionally rec-
ommend advising unsupervised back exercises (PICO
20; moderate-quality evidence; vote 91% a... | 48,431 | 50,931 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0027 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 27 | , we strongly
recommend treatment with total hip arthroplasty over no
surgery (PICO 25; very low-quality evidence; vote 100%
agreement).
Evidence and rationale. Evidence for the effec-
tiveness of total hip arthroplasty in patients with AS
included observational studies and case series which dem-
onstrated postoperativ... | 50,681 | 53,181 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0028 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 28 | s of individual
patients. The panel thought that in most patients the risks
would outweigh the potential benefits. However, elective
spinal osteotomy could be considered in those patients with
severe kyphosis who lack horizontal vision and for whom
this causes major physical and psychological impairments.
In this highl... | 52,931 | 53,642 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0029 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 29 | In adults with AS and acute iritis, we strongly recom-
mend treatment by an ophthalmologist to decrease the
severity, duration, or complications of episodes (PICO
27; very low-quality evidence; vote 100% agreement).
Evidence and rationale. No studies were identi-
fied that examined the relative effectiveness of treat-
... | 53,644 | 56,144 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0030 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 30 | 98/abstract). Data on adalimumab were
less extensive than data on infliximab. With some evi-
dence of differential effectiveness through indirect com-
parisons and no evidence of increased harms, the panel
recommended infliximab or adalimumab over etaner-
cept
for
patients
with
frequently
recurrent
iritis
episodes.
The... | 55,894 | 58,394 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0031 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 31 | doi/10.1002/art.39298/abstract).
Adalimumab was also associated with lower risks, although
these associations were not as strong as those of inflixi-
mab. The overall level of evidence was rated as very low
because of risk of bias, inconsistency, and imprecision. In
making the recommendation, the panel extrapolated
fro... | 58,144 | 58,642 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0032 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 32 | E. Education and preventive care
In adults with AS, we conditionally recommend partici-
pation in formal group or individual self-management
education (PICO 48; moderate-quality evidence; vote
91% agreement).
Evidence and rationale. Self-management educa-
tion interventions in AS were tested in 5 controlled trials,
wit... | 58,644 | 61,144 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0033 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 33 | spine as well as
the hips, compared to DXA scanning solely of the hip or
other non-spine sites (PICO 50; very low-quality evi-
dence; vote 100% agreement).
Evidence and rationale. We did not identify any
studies that compared different strategies of osteoporosis
screening in patients with AS. Because osteoporosis is a... | 60,894 | 63,394 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0034 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 34 | s for investigation.
Screening of asymptomatic patients with echo-
cardiography for aortic valve disease would not likely
detect occult abnormalities that could be treated to pre-
vent progression to a symptomatic stage. The highly sen-
sitive nature of echocardiography may lead to detection
of minor abnormalities and ... | 63,144 | 63,539 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0035 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 35 | Figure 3. Summary of the main recommendations for the treatment of patients with active ankylosing spondylitis (AS) (A) or stable AS (B).
NSAIDs 5 nonsteroidal antiinflammatory drugs; SSZ 5 sulfasalazine; TNFi 5 tumor necrosis factor inhibitors; IBD 5 inflammatory bowel disease;
GC 5 glucocorticoid; CRP 5 C-reactive pr... | 63,541 | 63,919 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0036 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 36 | judged that the undesirable consequences of screening,
including its costs, outweighed the potential benefits.
F. Recommendations for the treatment of patients
with nonradiographic axial SpA
The panel considered 20 PICO questions on phar-
macologic treatment, use of rehabilitation, and monitor-
ing of nonradiographic a... | 63,921 | 66,421 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0037 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 37 | e recommendations, we tried
to identify the most common, consequential, and unset-
tled questions in the care of patients with AS and nonra-
diographic axial SpA, so that the recommendations
would be useful in guiding clinical decision making. We
prioritized symptoms, health status, functional status,
quality of life, ... | 66,171 | 68,671 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0038 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 38 | s of treatment options.
For some questions, including most of those for
patients with nonradiographic axial SpA, we did not iden-
tify any directly relevant data from the literature. In these
cases, recommendations were based on the experience
and knowledge of voting panel members, and using indi-
rect evidence from ot... | 68,421 | 69,113 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0039 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 39 | ity and response. More studies are needed on the role of
systemic and local glucocorticoids, on the use of NSAIDs
in patients with coexisting inflammatory bowel disease,
and comparison of active versus passive physical therapy
treatments. Studies of appropriate methods to screen for
osteoporosis and cardiovascular dise... | 69,115 | 71,615 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0040 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 40 | e
thank our patient representative for adding valuable perspec-
tives. We thank Laurie Savage and Charlotte Howard of the
Spondylitis Association of America for their partnership on this
project. We thank Regina Parker for administrative assistance
and Tamara Rader, who with Janet Joyce, developed and
reviewed the lite... | 71,365 | 73,865 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0041 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 41 | ados M, Mijiyawa M. Criteria of the classification
of spondylarthropathies. Rev Rhum Mal Osteoartic 1990;57:
85–9. In French.
7. Dougados M, van der Linden S, Juhlin R, Huitfeldt B, Amor B,
Calin A, et al, and the European Spondylarthropathy Study
Group. The European Spondylarthropathy Study Group prelimi-
nary criteri... | 73,615 | 75,358 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0042 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 42 | 14. Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G,
et al. GRADE guidelines: 2. Framing the question and deciding
on important outcomes. J Clin Epidemiol 2011;64:395–400.
15. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al.
GRADE guidelines: 1. Introduction-GRADE evidence profiles
and summary of fi... | 75,360 | 77,860 |
acr-axial-spondyloarthritis-2015-482927f926-chunk-0043 | acr-axial-spondyloarthritis-2015-482927f926 | axial-spondyloarthritis | ACR | 2,015 | 43 | ;63:E90–4.
26. Loh AR, Acharya NR. Incidence rates and risk factors for ocu-
lar complications and vision loss in HLA-B27-associated uveitis.
Am J Ophthalmol 2010;150:534–42.
27. Forrest K, Symmons D, Foster P. Systematic review: is ingestion
of paracetamol or non-steroidal anti-inflammatory drugs associ-
ated with exa... | 77,610 | 78,551 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0000 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 0 | 1599
Arthritis & Rheumatology
Vol. 71, No. 10, October 2019, pp 1599–1613
DOI 10.1002/art.41042
© 2019, American College of Rheumatology. This article has been contributed to by US Government employees
and their work is in the public domain in the USA.
S P E C I A L A R T I C L E
2019 Update of the American College of... | 0 | 2,500 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0001 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 1 | ics 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 radio-
graph... | 2,250 | 3,903 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0002 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 2 | WARD ET AL
1600 |
INTRODUCTION
Axial spondyloarthritis (SpA), comprising ankylosing spon-
dylitis (AS) and nonradiographic axial SpA, is the main form of
chronic inflammatory arthritis affecting the axial skeleton (1).
AS affects 0.1–0.5% of the population, and is characterized by
inflammatory back pain, radiogra... | 3,905 | 6,405 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0003 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 3 | ysical therapists,
and others providing care to patients with axial SpA.
METHODS
These recommendations followed ACR and Grading of Recom-
mendations, Assessment, Development and Evaluation (GRADE)
methodology (8,9), as described in Supplementary Appendix 1,
available on the Arthritis & Rheumatology web site at http://o... | 6,155 | 8,655 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0004 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 4 | te, Toronto Western Hospital, Toronto, Ontario, Canada;
8David Borenstein, MD: Arthritis & Rheumatism Associates, Washington,
DC; 9Runsheng Wang, MD, MHS: Columbia University Medical Center, New
York, New York; 10Meika A. Fang, MD: VA West Los Angeles Medical Center,
Los Angeles, California; 11Grant Louie, MD, MHS: Art... | 8,405 | 10,905 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0005 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 5 | of interest during
the time of guideline development, but just before publication became the
site principal investigator for clinical trials for systemic lupus erythematosus
by Bristol-Myers Squibb and Janssen. Dr. Maksymowych has received
consulting fees from AbbVie, Boehringer, Celgene, Galapagos, Janssen, Eli
Lilly ... | 10,655 | 11,350 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0006 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 6 | ACR/SAA/SPARTAN 2019 TREATMENT RECOMMENDATIONS IN AS
| 1601
RESULTS
Here we present the recommendations that were reviewed in
this update, whether it was a new recommendation (designated
“new”) or reevaluation of an existing recommendation. Table 2
and Table 3 provide all current recommendations, including
those... | 11,352 | 13,852 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0007 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 7 | adherence,
after having a sustained clinically meaningful improvement on treatment (generally, beyond the
initial 6 months of treatment).
Conventional synthetic
antirheumatic drug
Sulfasalazine, methotrexate, leflunomide, apremilast, thalidomide, pamidronate.
Biosimilar
Biopharmaceuticals that are copies of an origina... | 13,602 | 16,102 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0008 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 8 | king
The process by which a patient and clinician arrive at an individualized treatment decision based on
an understanding of the potential benefits and risks of available treatment options and of a
patient’s values and preferences.
* TNFi = tumor necrosis factor inhibitor.
**Correction added on 26 September 2019, afte... | 15,852 | 16,307 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0009 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 9 | WARD ET AL
1602 |
Table 2. Recommendations for the treatment of adults with AS*
Recommendation
Level of
evidence
PICO
RECOMMENDATIONS FOR ADULTS WITH ACTIVE AS
1. We strongly recommend treatment with NSAIDs over no treatment with NSAIDs.†
Low
2
2. We conditionally recommend continuous treatment with NSAIDs over ... | 16,309 | 18,809 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0010 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 10 | ionally recommend treatment with a
different TNFi over treatment with a non-TNFi biologic in patients with secondary nonresponse to TNFi.
Very low
10
14. In adults with active AS despite treatment with the first TNFi used, we strongly recommend against switching to
treatment with a biosimilar of the first TNFi.
Very ... | 18,559 | 21,059 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0011 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 11 | a conventional synthetic antirheumatic drug, we conditionally recom-
mend continuing treatment with TNFi alone over continuing both treatments.
Very low
12
26. In adults receiving treatment with a biologic, we conditionally recommend against discontinuation of the biologic.
Very low to
low
66
(Continued) | 20,809 | 21,115 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0012 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 12 | ACR/SAA/SPARTAN 2019 TREATMENT RECOMMENDATIONS IN AS
| 1603
Recommendation
Level of
evidence
PICO
27. In adults receiving treatment with a biologic, we conditionally recommend against tapering of the biologic dose as
a standard approach.
Very low to
low
65
28. In adults receiving treatment with an originator TNF... | 21,117 | 23,617 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0013 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 13 | h inflammatory bowel disease, we conditionally recommend treatment with TNFi monoclonal antibod-
ies over treatment with other biologics.
Very low
32
DISEASE ACTIVITY ASSESSMENT, IMAGING, AND SCREENING
42. We conditionally recommend the regular-interval use and monitoring of a validated AS disease activity
measure.†
V... | 23,367 | 25,729 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0014 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 14 | WARD ET AL
1604 |
Table 3. Recommendations for the treatment of adults with nonradiographic axial SpA*
Recommendation
Level of
evidence
PICO
RECOMMENDATIONS FOR ADULTS WITH ACTIVE NONRADIOGRAPHIC AXIAL SpA
52. We strongly recommend treatment with NSAIDs over no treatment with NSAIDs.†
Very low
34
53. We conditio... | 25,731 | 28,231 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0015 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 15 | ults with active nonradiographic axial SpA and secondary nonresponse to the first TNFi used, we conditionally
recommend switching to a different TNFi over switching to a non-TNFi biologic.
Very low
42
65. In adults with active nonradiographic axial SpA despite treatment with the first TNFi used, we strongly recommend... | 27,981 | 30,481 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0016 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 16 | iving treatment with TNFi and a conventional synthetic antirheumatic drug, we conditionally recom-
mend continuing treatment with TNFi alone over continuing treatment with both medications.
Very low
44
77. In adults receiving treatment with a biologic, we conditionally recommend against discontinuation of the
biologic... | 30,231 | 30,912 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0017 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 17 | ACR/SAA/SPARTAN 2019 TREATMENT RECOMMENDATIONS IN AS
| 1605
uncertainty regarding potential disease-modifying effects, the com-
mittee conditionally favored continuous use of NSAIDs in patients
with active AS, primarily for controlling disease activity. The decision
to use NSAIDs continuously may vary depending o... | 30,914 | 33,414 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0018 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 18 | dy of tofacitinib showed benefit in both clinical
and imaging outcomes of axial disease over 12 weeks (20). Use of
tofacitinib could be another option, although the results of phase
III trials are not available. Leflunomide, apremilast, thalidomide, and
pamidronate are not recommended (See Supplementary Appendix
6, ava... | 33,164 | 35,664 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0019 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 19 | In adults with stable nonradiographic axial SpA, we conditionally recommend against obtaining a spinal or pelvis
MRI to confirm inactivity.
Very low
82
86. In adults with active or stable nonradiographic axial SpA on any treatment, we conditionally recommend against
obtaining repeat spine radiographs at a scheduled i... | 35,414 | 36,375 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0020 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 20 | WARD ET AL
1606 |
tion for use of TNFi in patients whose AS remained active (as
defined in Table 1) despite treatment with NSAIDs. The panel
recommended that lack of response (or intolerance) to at least 2
different NSAIDs at maximal doses over 1 month, or incomplete
responses to at least 2 different NSAIDs over ... | 36,377 | 38,877 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0021 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 21 | The use of secukinumab and ixekizumab in patients with
active AS is supported by data from large placebo-controlled trials
(see Supplementary Appendix 6, on the Arthritis & Rheumatology
web site at http://onlinelibrary.wiley.com/doi/10.1002/art.41042/
abstract). The panel recommended use of TNFi over secukinumab
or ix... | 38,627 | 41,127 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0022 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 22 | pite treatment with the first
TNFi used, we conditionally recommend treatment with secuki-
numab or ixekizumab over treatment with a different TNFi in
patients with primary nonresponse to TNFi (new, PICO 10).
In adults with active AS despite treatment with the first
TNFi used, we conditionally recommend treatment with
... | 40,877 | 42,201 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0023 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 23 | ACR/SAA/SPARTAN 2019 TREATMENT RECOMMENDATIONS IN AS
| 1607
50% improvement in Bath AS Disease Activity Index) to the second
TNFi (28–30). However, not all patients in these studies switched
TNFi because of ineffectiveness.
The panel judged that treatment should differ for patients
who had a primary nonresponse to... | 42,203 | 44,703 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0024 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 24 | ents who receive co-treatment with methotrex-
ate, perhaps by reducing the development of antidrug antibodies
(31). In AS, it is less clear whether the duration of TNFi use, and
by inference their effectiveness, is similarly prolonged (32). Data
from observational studies are conflicting, although some studies,
primar... | 44,453 | 46,953 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0025 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 25 | In stable patients, a trial of withdrawing either the
NSAIDs or the csARD should be considered, due to the likeli-
hood of greater toxicity with the long-term use of more than one
medication. However, on-demand NSAID treatment for control of
intermittent symptoms is recommended for patients with good
responses to pr... | 46,703 | 47,917 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0026 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 26 | WARD ET AL
1608 |
continued long-term, barring toxicities. Discontinuation might be
considered in patients in sustained remission (i.e., several years),
with the anticipation that only one-third of patients would not
experience relapse. Patient preferences should help guide this
decision.
Tapering of TNFi could... | 47,919 | 50,419 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0027 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 27 | ties
In adults with AS and recurrent uveitis, we conditionally
recommend treatment with TNFi monoclonal antibodies over
treatment with other biologics (PICO 29).
Evidence for this recommendation is limited to indirect com-
parisons of the rates of acute uveitis episodes in clinical trials or
observational studies, rath... | 50,169 | 52,669 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0028 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 28 | ment of Crohn’s disease, and infliximab, adalimumab, and
golimumab are approved for the treatment of ulcerative colitis,
while etanercept is not approved for either condition (42,43).
This evidence is the basis for the recommendation favoring
TNFi monoclonal antibody use in patients with AS and coexist-
ing IBD. The ch... | 52,419 | 53,859 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0029 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 29 | ACR/SAA/SPARTAN 2019 TREATMENT RECOMMENDATIONS IN AS
| 1609
Therefore, the recommendations for nonradiographic axial SpA
were largely extrapolated from evidence in AS (Table 3). The rec-
ommendations were identical in both patient groups with 1 nota-
ble exception: treatment with secukinumab or ixekizumab was
stro... | 53,861 | 56,361 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0030 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 30 | radiographic axial SpA of unclear
activity while receiving a biologic, we conditionally recom-
mend obtaining a pelvis MRI to assess activity (new, PICO 81).
Because physical and laboratory measures are often normal
despite active axial SpA, and because symptoms may be non-
specific, it may be difficult to know wheth... | 56,111 | 58,611 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0031 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 31 | ormalities for measurement of activity in
axial SpA, the burden of testing, and concern for possible
overtreatment, the panel recommended against obtaining
an MRI in this setting. MRI could be considered in circum-
stances where the clinician and patient differ in their assess-
ment of whether the disease is stable.
In... | 58,361 | 59,602 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0032 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 32 | WARD ET AL
1610 |
A
B
Figure 1. Summary of the main recommendations for the treatment of patients with A, active ankylosing spondylitis and B, stable ankylosing
spondylitis. AS = ankylosing spondylitis; NSAIDs = nonsteroidal antiinflammatory drugs; GC = glucocorticoid; SSZ = sulfasalazine; MTX =
methotrexate; LE... | 59,604 | 60,397 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0033 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 33 | ACR/SAA/SPARTAN 2019 TREATMENT RECOMMENDATIONS IN AS
| 1611
spine radiographs at a regular interval leads to better patient out-
comes, and data balancing a clinical benefit with the risk of radiation
exposure are absent. Therefore, the panel recommended against
repeating spine radiographs as a standard approach. ... | 60,399 | 62,899 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0034 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 34 | amidronate were suggested as alternatives for the treat-
ment of patients with active disease and contraindications to
TNFi, while the current recommendations suggest use of secuki-
numab or ixekizumab in most of these cases (except patients
with high risk of infections). In cases of failure of TNFi, the 2015
guideline... | 62,649 | 65,149 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0035 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 35 | d against
obtaining spine radiographs on scheduled intervals to monitor
progression. This practice entails radiation exposure and would
not alter treatment in most cases.
We used the GRADE method to develop these treatment
recommendations in a way that was transparent, systematic,
and explicit, and that was informed by... | 64,899 | 66,543 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0036 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 36 | WARD ET AL
1612 |
careful assessment, sound clinical judgment of each patient’s
circumstances, and consideration of a patient’s preferences.
ACKNOWLEDGMENTS
We thank Cassie Shafer and Elin Aslanyan of the SAA for
their partnership on this project. We thank SPARTAN for its part-
nership on this project. We thank o... | 66,545 | 69,045 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0037 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 37 |
5. Boonen A, Sieper J, van der Heijde D, Dougados M, Bukowski JF,
Valluri S, et al. The burden of non-radiographic axial spondyloarthri-
tis. Sem Arthritis Rheum 2015;44:556–62.
6. Ward MM. Quality of life in patients with ankylosing spondylitis.
Rheum Dis Clin North Am 1998;24:815–27.
7. Ward MM, Deodhar A, Ak... | 68,795 | 71,295 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0038 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 38 | nd treatment of an-
kylosing spondylitis with diclofenac over 2 years on radiographic
progression of the spine: results from a randomised multicentre trial
(ENRADAS). Ann Rheum Dis 2016;75:1438–43.
14. Khanna Sharma S, Kadiyala V, Naidu G, Dhir V. A randomized con-
trolled trial to study the efficacy of sulfasalazine ... | 71,045 | 73,465 |
acr-axial-spondyloarthritis-2019-90265c3f66-chunk-0039 | acr-axial-spondyloarthritis-2019-90265c3f66 | axial-spondyloarthritis | ACR | 2,019 | 39 | ACR/SAA/SPARTAN 2019 TREATMENT RECOMMENDATIONS IN AS
| 1613
of efficacy and safety of etanercept and infliximab in patients with
ankylosing spondylitis. Rheumatol Int 2010;30:1437–40.
24. Souto A, Maneiro JR, Salgado E, Carmona L, Gomez-Reino JJ. Risk
of tuberculosis in patients with chronic immune-mediated inf... | 73,467 | 75,967 |
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