ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update

Abstract

ObjectivesTo update the Assessment of SpondyloArthritis international Society (ASAS)-EULAR recommendations for the management of axial spondyloarthritis (axSpA).MethodsFollowing the EULAR Standardised Operating Procedures, two systematic literature reviews were conducted on non-pharmacological and pharmacological treatment of axSpA. In a task force meeting, the evidence was presented, discussed, and overarching principles and recommendations were updated, followed by voting.ResultsFive overarching principles and 15 recommendations with a focus on personalised medicine were agreed: eight remained unchanged from the previous recommendations; three with minor edits on nomenclature; two with relevant updates (#9, 12); two newly formulated (#10, 11). The first five recommendations focus on treatment target and monitoring, non-pharmacological management and non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice pharmacological treatment. Recommendations 6–8 deal with analgesics and discourage long-term glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for pure axial involvement. Recommendation 9 describes the indication of biological DMARDs (bDMARDs, that is, tumour necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i)) and targeted synthetic DMARDs (tsDMARDs, ie, Janus kinase inhibitors) for patients who have Ankylosing Spondylitis Disease Activity Score ≥2.1 and failed ≥2 NSAIDs and also have either elevated C reactive protein, MRI inflammation of sacroiliac joints or radiographic sacroiliitis. Current practice is to start a TNFi or IL-17i. Recommendation 10 addresses extramusculoskeletal manifestations with TNF monoclonal antibodies preferred for recurrent uveitis or inflammatory bowel disease, and IL-17i for significant psoriasis. Treatment failure should prompt re-evaluation of the diagnosis and consideration of the presence of comorbidities (#11). If active axSpA is confirmed, switching to another b/tsDMARD is recommended (#12). Tapering, rather than immediate discontinuation of a bDMARD, can be considered in patients in sustained remission (#13). The last recommendations (#14, 15) deal with surgery and spinal fractures.ConclusionsThe 2022 ASAS-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.

Janus Kinase Inhibitors: A New Tool for the Treatment of Axial Spondyloarthritis

“…Table 3 summarizes the main features and results obtained from the major studies of JAKinib in axSpA therapy. In Figure 3 , a flow chart for selecting biologics and JAKinibs for patients with axSpa is provided, in accordance with ASAS-EULAR recommendations [ 100 ].…”

Disease activity indexes might not capture the same disease aspects in males and females with ankylosing spondylitis: A real-world nationwide analysis

“…All these clinical differences could at least partially explain why ASDAS may not be sensitive enough to detect gender differences in disease activity ( 14 , 16 ). We acknowledge that ASDAS is the preferred and most recommended index to evaluate disease activity nowadays, for different reasons ( 17 ). However, when the above-mentioned manifestations are predominant, the ASDAS could be underestimating disease activity.…”

Greetings from the editor 2023

“…10 11 Indeed, as hopefully exemplified in these recommendations, challenges are here to be recognised and tackled in a comprehensive way. Other updates deal with axial spondyloarthritis, [12][13][14] vaccination in children with rheumatic diseases 15 and lifestyle behaviour. 16 These are complemented by points to consider work participation 17 and therapeutic drug monitoring.…”