2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

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Abstract

Objective.

To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).

Methods.

We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel.

Results.

Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary non-response to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics 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 radiographs is not recommended.

Conclusion.

These recommendations provide updated guidance regarding use of new medications and axial imaging in the management of patients with AS and those with nonradiographic axial SpA.

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Most cited references 29

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Tofacitinib as Induction and Maintenance Therapy for Ulcerative Colitis

William J Sandborn, Chinyu Su, Bruce Sands … (2017)

Tofacitinib, an oral, small-molecule Janus kinase inhibitor, was shown to have potential efficacy as induction therapy for ulcerative colitis in a phase 2 trial. We further evaluated the efficacy of tofacitinib as induction and maintenance therapy.

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ACG Clinical Guideline: Management of Crohn’s Disease in Adults

Bruce Sands, Edward V Loftus, Kim L Isaacs … (2018)

Crohn's disease is an idiopathic inflammatory disorder of unknown etiology with genetic, immunologic, and environmental influences. The incidence of Crohn's disease has steadily increased over the past several decades. The diagnosis and treatment of patients with Crohn's disease has evolved since the last practice guideline was published. These guidelines represent the official practice recommendations of the American College of Gastroenterology and were developed under the auspices of the Practice Parameters Committee for the management of adult patients with Crohn's disease. These guidelines are established for clinical practice with the intent of suggesting preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When exercising clinical judgment, health-care providers should incorporate this guideline along with patient's needs, desires, and their values in order to fully and appropriately care for patients with Crohn's disease. This guideline is intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. To evaluate the level of evidence and strength of recommendations, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The Committee reviews guidelines in depth, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time.

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Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee.

Asher Kornbluth, David Sachar (2010)

Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

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Author and article information

Journal

Journal ID (nlm-journal-id): 101623795

Journal ID (pubmed-jr-id): 42112

Journal ID (nlm-ta): Arthritis Rheumatol

Title: Arthritis & rheumatology (Hoboken, N.J.)

ISSN (Print): 2326-5191

ISSN (Electronic): 2326-5205

Publication date Nihms-submitted: 6 September 2019

Publication date (Electronic): 22 August 2019

Publication date (Print): October 2019

Publication date PMC-release: 01 October 2020

Volume: 71

Issue: 10

Pages: 1599-1613

Affiliations

[1 ]National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland

[2 ]Oregon Health & Science University, Portland, Oregon

[3 ]University of California, San Francisco

[4 ]Boston University School of Medicine, Boston, Massachusetts

[5 ]University of California, Los Angeles

[6 ]Case Western Reserve University, Cleveland, Ohio

[7 ]University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada

[8 ]Arthritis & Rheumatism Associates, Washington, DC

[9 ]Columbia University Medical Center, New York, New York

[10 ]VA West Los Angeles Medical Center, Los Angeles, California

[11 ]Arthritis and Rheumatism Associates, Wheaton, Maryland

[12 ]University of Mississippi Medical Center, Jackson, Mississippi

[13 ]University of Washington, Seattle

[14 ]Seattle, Washington

[15 ]Pianin and Associates, PC, Phoenix, Arizona

[16 ]American College of Rheumatology, Atlanta, Georgia

[17 ]ECRI Institute, Plymouth Meeting, Pennsylvania

[18 ]University of Alberta, Edmonton, Alberta, Canada

[19 ]Rocky Mountain Regional VA Medical Center and University of Colorado, Aurora.

Author notes

AUTHOR CONTRIBUTIONS

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Ward had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Address correspondence to Michael M. Ward, MD, MPH, NIAMS/NIH, Building 10 CRC, Room 4-1339, 10 Center Drive, MSC 1468, Bethesda, MD 20892. wardm1@ 123456mail.nih.gov .

Article

Accession ID: PMC6764882 Pmcid ID: PMC6764882 Pmc-uid ID: 6764882 Manuscript ID: nihpa1042290

DOI: 10.1002/art.41042

PMC ID: 6764882

PubMed ID: 31436036

SO-VID: 7c0d0c16-f440-4fb0-868f-a690a46074e7

2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

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Abstract

Objective.

Methods.

Results.

Conclusion.

Related collections

Karger: Ophthalmology

Most cited references 29

Tofacitinib as Induction and Maintenance Therapy for Ulcerative Colitis

ACG Clinical Guideline: Management of Crohn’s Disease in Adults

Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee.

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