2016 update of the ASAS-EULAR management recommendations
13 ???. 2017 ?. Ann Rheum Dis 2017;76:978–991. doi:10.1136/annrheumdis-2016-210770. Recommendation. To cite: van der Heijde D. Ramiro S
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2016 updateofthe ASAS-EULARmanagement
recommendationsforaxial spondyloarthritisDésirée vander Heijde,
1Soa Ramiro,
1RobertLande wé,
2,3Xenofon Baraliakos,
4Filip VandenBosch,
5AlexandreSepriano,
1,6AndreaR egel,
4Adrian Ciurea,
7Hanne Dagnrud,
8MaximeDougados,
9,10Floris vanGaalen,
1Pál Géher,
11Irenevan derHors t-Bruinsma,
12RobertD Inman,
13Merryn Jongkees,
14Uta Kiltz,
4ToreKKvien,
15PedroMMa chado,
16Helena Marzo-Ortega,
17,18Anna Molto,
9,10Victoria Navarro-Compàn,
19Salih Ozgocmen,
20FernandoM Pimentel-Santos,
21John Reveille,
22Martin Rudwaleit,
23,24,25
Jochen Sieper,
26PercivalSampaio-Barros,
27Dieter Wiek,
28Jürgen Braun
4ABSTRACT
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 tRheumatism(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 rTNFi 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.INTRODUCTIONAxial spondyloarthritis(axSpA) isan inammatory
rheumaticdiseasewith adiv erseclinical presenta- tion. 1Chronicba 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. 2Historically,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. 3Only recentlyithas beenpr operlya cknowl-
edged thatradiogr aphicsacroiliitisisa ratherlate nding inthe diseasecourse ofmany patients, thatMRI mayshow signsofinammationmuch earlier
than radiographsshows tructuraldamage,and that patientscan alsobe diagnosedbased ona typical clinical pattern,even inthepresence ofnormal imaging tests. 14The termaxSpA comprisesthe
whole spectrumof patients withradiographic sacroiliitis(ASor radiogr aphicaxSpA) andwithout radiographicsacr oiliitis(non-radiographicaxSpA). 4Thereis 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. 5However,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 alAnn 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.nlReceived 4 November 2016
Revised 29 November 2016
Accepted 5 December 2016
Published Online First
13January2017
yhttp://dx.doi.org/10.1136/ annrheumdis-2016-211005on September 27, 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. 6-10Takentogether, thereisample argumenttouseonly
the termaxSpA inclinical pra ctice. 11Especially 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. 12-17The 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-quotesdbs_dbs30.pdfusesText_36[PDF] 2018 art calendars
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