Thursday, 21 Nov 2019

You are here

ACR/SPARTAN Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

The American College of Rheumatology (ACR), in partnership with the Spondylitis Association of America (SAA) and the Spondyloarthritis Research and Treatment Network (SPARTAN), released the 2019 Update of the Recommendations for the Treatment of Ankylosing Spondylitis (AS) and Nonradiographic Axial Spondyloarthritis (nr-axSpA). The guideline includes 86 recommendations that provide updated and new guidance for the management of patients with AS and nr-axSpA in the areas of pharmacologic and non-pharmacologic treatment options; AS-related comorbidities; and disease activity assessment, imaging, and screening.

“SAA is proud to be a co-sponsor of these updated guidelines. SAA is committed to expanding treatment options and ensuring that both spondyloarthritis patients and the medical practitioners that are entrusted with their care have the best resources to aid in their decision-making,” said Cassie Shafer, chief executive officer of the SAA. 

Axial SpA, which is comprised of AS and nr-axSpA, is the main form of chronic inflammatory arthritis affecting the axial skeleton. This condition is characterized by back and hip pain, peripheral joint pain, and fatigue, all of which can vary in severity. According to the SAA, as much as 1 percent of the adult United States population may have axial SpA. This means that as many as 2.7 million adults may be affected by the disease. 

The ACR’s previous guideline, published in 2015, provided recommendations for pharmacological treatments, management of selected comorbidities, disease monitoring, and preventive care. The 2019 update builds on these recommendations by adding information on new medications, managing biologic and biosimilars usage in patients, and best practices for utilizing imaging (MRI and radiographs). 

“Based on the literature, we felt it was important to address topics such as sequencing biologics for patients with active AS despite NSAID usage, whether to taper or discontinue biologics in the setting of remission, and clearer guidelines on when to obtain images – particularly in instances when results would likely lead to a change in treatment,” said Michael Ward, MD, MPH, researcher at the National Institute of Arthritis and Musculoskeletal and Skin Diseases and principal investigator of the guideline. “We hope this new information will help get patients on an effective treatment faster and ultimately improve patients’ health status and quality of life.” 

To update the guideline, a team of experts conducted a systematic literature review for 20 clinical questions on pharmacological treatment addressed in the 2015 guidelines along with 26 new questions on pharmacological treatment, treat-to-target strategy, and the use of imaging. The results of this review were then discussed by a separate voting panel and crafted into recommendations that were labeled conditional or strong based on the evidence available. A few of the recommendations from the guideline include: 

  • A strong recommendation to treat adults with active AS despite treatment with NSAIDs with a TNFi (no preferred choice) over no treatment with a TNFi.
  • A conditional recommendation to treat with a TNFi over treatment with secukinumab, ixekizumab or tofacitinib, and a conditional recommendation to treat with seukinumab or ixekizumab over tofacitinib.
  • A strong recommendation to continue treatment with the originator biologic over mandated switching to its biosimilar for adults with stable AS.
  • A conditional recommendation against obtaining repeat spine radiographs at a scheduled interval as a standard approach for adults with active or stable nr-axSpA on any treatment.

“These guidelines update those from four years ago by consolidating the expert thought around the use of the newest therapeutic agents and modifying a number of recommendations from the 2015 guideline to reflect recent evidence. They provide patients and the medical community with clear recommendations for spondyloarthritis management using a rigorous approach, and SPARTAN is proud to endorse them,” said Dr. Liron Caplan, chair of SPARTAN. 

ACR guidelines are currently developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which creates rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations. Due to limited data in some areas, the quality of evidence was most often low, very low or occasionally moderate. This led to nearly all recommendations being conditional, with only a few strong recommendations in cases in which there was sufficient evidence.

See the updated and expanded recommendations, supporting PICO questions and evidence report on the  Axial Spondyloarthritis Guideline page.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

New Treatments in Axial SpA from #ACR2019

There were new developments in the treatment of axial Spondyloarthritis (AS) at ACR 2019. The first area is on the use of anti-IL17A drugs, secukinumab and ixekizumab in non-radiographic AS. The second area is the use of JAK-1 inhibitor Upadacitinib in radiographic AS. The third area is the use of dual anti-IL17A and 17F drug bimekizumab in radiographic.

Most Psoriatics Go on Biologics

A cohort study of 97 patients with psoriatic arthritis (PsA) examined the prescribing practices in PsA, and found biologics are commonly initiated as the primary mode of therapy in outpatients with PsA. However, treatment modifications can be made regarding patients who are managed with apremilast alone.

Year in Review - Psoriatic Arthritis 2019

Major new insights into the treatment of psoriatic arthritis dominated the headlines during the past year, with a head-to-head trial comparing IL-17A inhibition with tumor necrosis factor blockade, another study considering whether methotrexate can improve outcomes with anti-TNF therapy in PsA, and an investigation into the effects of biologic therapy on bone.

EXCEED Study: Cosentyx Equals Humira in Psoriatic Arthritis

Novartis has announced the results of the EXCEED trial that pitted its IL-17 inhibitor, Cosentyx (secukinumab - SEC) against Humira (adalimumab - ADA) in patients with active psoriatic arthritis. The trial demonstrated that SEC was not non-inferior to ADA, but failed to meet its primary endpoint of superiority over ADA as far as drug efficacy.

Rinvoq (upadacitinib) Effective in Psoriatic Arthritis

Yesterday, AbbVie reported the top-line study results showing the efficacy of Rinvoq (upadacitinib - UPAD) adult patients with active psoriatic arthritis who previously had an inadequate response to a biologic DMARD.