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2016 updateofthe ASAS-EULARmanagement

recommendationsforaxial spondyloarthritis

Désirée vander Heijde,

1

Soa Ramiro,

1

RobertLande wé,

2,3

Xenofon Baraliakos,

4

Filip VandenBosch,

5

AlexandreSepriano,

1,6

AndreaR egel,

4

Adrian Ciurea,

7

Hanne Dagnrud,

8

MaximeDougados,

9,10

Floris vanGaalen,

1

Pál Géher,

11

Irenevan derHors t-Bruinsma,

12

RobertD Inman,

13

Merryn Jongkees,

14

Uta Kiltz,

4

ToreKKvien,

15

PedroMMa chado,

16

Helena Marzo-Ortega,

17,18

Anna Molto,

9,10

Victoria Navarro-Compàn,

19

Salih Ozgocmen,

20

FernandoM Pimentel-Santos,

21

John Reveille,

22

Martin Rudwaleit,

23,24,25

Jochen Sieper,

26

PercivalSampaio-Barros,

27

Dieter Wiek,

28

Jürgen Braun

4

ABSTRACT

Toupda teandintegr ate therecommendationsfor

ankylosing spondylitisandthe recommenda tionsfor the use oftumour necrosis factorinhibitors(TNFi) inaxial spondyloarthritis(axSpA) intoone setapplicable tothe full spectrumofpa tientswith axSpA.Following the latestversion oftheEuropean LeagueAgains t

Rheumatism(EULAR) Standardised Operating

Procedures,twos ys tematicliteraturereviewsrst

collected theeviden ceregarding alltreatmentoptions (pharmacologicalandnon-pharma cological )thatwere published since2009. Aftera discussionof ther esults in thes teeringgroupand presentationto thetask force, overarchingprinciplesandrecommenda tionsw ere formulated,and consensusw asobt ainedbyinformal voting.A totalof 5o ver arching principlesand13 recommendationswere agreedon.Therstthr ee recommendationsdealwithpersonali sedmedicine including treatmenttargetandmonitoring.

Recommendation4co vers non-pharmacological

management.R ecommendation5describesthece ntral roleofnon-s teroidal anti-inammatorydrugs (NSAIDs) asrst-choicedrugtr eatment .Recommendations6-8 dene ther athermodestrole ofanalgesics,and disproveglucocorticoidsand conventionals ynthetic disease-modifying antirheumaticdrugs(DMARDs) for axSpA patentswithpr edominant axialinvolvement.

Recommendation9r efers tobiologicalDMARDs

(bDMARDs) includingTNFiand IL-17inhibitors (IL-17i) for patientswithhigh disease activit ydespitetheuse (or intolerance/contraindication)ofatleas ttwo NSAIDs.

In addition,they shouldeitherhav ean elevated C

reactiveproteinand/or denite inammationon MRI and/or radiographicevidenceofsacr oiliitis.Curr ent practiceisto start witha TNFi.Switchingtoanothe r

TNFi oran IL-17iis recommende din caseTNFifails

(recommendation10).Tapering, butnot stoppinga bDMARD, canbe considered inpatientsin sustained remission(recommenda tion11).Thenal two recommendations(12,13)dea lwith surgery andspinal fractures.The2016Assessmen tof SpondyloArthritis internationalSociety-EUL ARrecommendations provide up-to-dateguida nceonthemanagement ofpa tients with axSpA.INTRODUCTION

Axial spondyloarthritis(axSpA) isan inammatory

rheumaticdiseasewith adiv erseclinical presenta- tion. 1

Chronicba ckpainisthe leadings ymptomof

the diseaseand oftenin ammatoryin natur ewith pronounceds tiffnessandimpro vement ofpainand stiffnesswith exer cise.Othermusculoskeletalmani- festationsofaxSpA are arthritis,enthesitis anddac- tylitis. Extra-articularmanifesta tionssuchas anterior uveitis,psoriasisand inammatorybo wel disease (IBD)(in orderof decreasing prevalence) arealso chara cteristicforaxSpA. 2

Historically,end-

stagepa tientswere recognisedbyachara cteristic stoopedpos tureandbythepr esenceof syndesmo- phytes onr adiographsofthespine.La ter, radio- graphicsa croiliitisbecameacrucialnding inthe diagnosis andclassi cationof patients. Themodi- ed NewYork criteriaforankylosingspondylitis (AS) weremostfr equentlyusedins tudiesanddrug trials. 3

Only recentlyithas beenpr operlya cknowl-

edged thatradiogr aphicsacroiliitisisa ratherlate nding inthe diseasecourse ofmany patients, that

MRI mayshow signsofinammationmuch earlier

than radiographsshows tructuraldamage,and that patientscan alsobe diagnosedbased ona typical clinical pattern,even inthepresence ofnormal imaging tests. 14

The termaxSpA comprisesthe

whole spectrumof patients withradiographic sacroiliitis(ASor radiogr aphicaxSpA) andwithout radiographicsacr oiliitis(non-radiographicaxSpA). 4

Thereis still somedebateas towhether radio-

graphicand non-radiogr aphicaxSpAshouldbe consideredas twodiffer ententities orasacontinu- ous diseasespectrum. Thecurr entlypr evailing opinion istha taxSpAencompassesone disease spectrum inwhich singlepa tientswith non- radiographicaxSpAma ydev elopradiographic changes overtime. 5

However,notallpatients with

non-radiographicaxSpAwill ultimately develop radiographicsacr oiliitis.Similarly,notallpa tients with radiographicsacroiliitis willultimatelydevelop syndesmophytes.In fact, radiographicsa croiliitis articially dividesthe spectrumof axSpAin two groups,and itis unlikely that thesolepresence of radiographicsacr oiliitisisrelevantforthe outcome van der Heijde D, et al

Ann Rheum Dis

2017;

:978-991. doi:10.1136/annrheumdis-2016-210770978van der Heijde D, et al. Ann Rheum Dis 2017;:978-991. doi:10.1136/annrheumdis-2016-210770

Recommendation

To cite:

van der HeijdeD,

RamiroS, LandewéR,

2017;
76
:978-991. yAdditional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ annrheumdis-2016-210770).

For numbered afliations see

end of article.

Correspondence to

Professor Désirée van der Heijde,

Department of Rheumatology,

Leiden University Medical

Center, PO Box 9600, Leiden

2300 RC, The Netherlands;

mail@dvanderheijde.nl

Received 4 November 2016

Revised 29 November 2016

Accepted 5 December 2016

Published Online First

13January2017

yhttp://dx.doi.org/10.1136/ annrheumdis-2016-211005

on October 23, 2023 by guest. Protected by copyright.http://ard.bmj.com/Ann Rheum Dis: first published as 10.1136/annrheumdis-2016-210770 on 13

January 2017. Downloaded from

of thedisease. Inaddition, recent studies andtrialshav ecast doubt onthe reliability ofestablishingr adiographic abnormal- ities. 6-10

Takentogether, thereisample argumenttouseonly

the termaxSpA inclinical pra ctice. 11

Especially inthe context

of studies,itma ybe ofvaluetoadd certainchar acteris ticsto the prole ofpa tients,suchasthe presence ofr adiographic sacroilii- tis, thepr esenceofinammationon MRI,the presence ofarth- ritis, ofe xtra-articularmanifestations,to describeindetailthe type ofpa tientsincluded. 5 Apart fromhistorical reasons,drugdev elopmenthasplay eda major roleindis tinguishingpa tientsbasedonthe presenceof radiographicsacr oiliitis:tumournecrosisfactor inhibitor(TNF i) therapyw ashistoricallyappr ovedfor patientswithAS,and companies soughtthe additionalr egulatory approvalfor patientswithout radiogr aphicsacroiliitis. 12-17

The newestdraft

guidance documentof theEur opeanMedicines Agencynow proposesto study patientswithaxSpA asoneentity, whichtes ti- es ofthe progr essintheeld ofaxSpA. 18 Historically,theAssessment ofSpondyloArthritis inter- nationalSociety (ASAS)has dra ftedtwo setsoftreatment recommendations,dating backtothe timewhenTNFiw ere the only classof biologicaldisease-modifying antirheuma ticdrugs (bDMARDs) andthe conceptof axSpAw asnot yet wellestab- lished. However,itshouldbenotedtha tther eis noformal prooftha tTNFiare infa ctdiseasemodifyingin axSpA.The rstset includedthe ASASr ecommendations forthe useof TNFi therapyinpa tientswith ASpublishedrstin 2003and updatedin 2006and 2010.quotesdbs_dbs47.pdfusesText_47

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