Michael M Ward1, Atul Deodhar2, Elie A Akl3, Andrew Lui4, Joerg Ermann5, Lianne S Gensler4, Judith A Smith6, David Borenstein7, Jayme Hiratzka2, Pamela F Weiss8, Robert D Inman9, Vikas Majithia10, Nigil Haroon9, Walter P Maksymowych11, Janet Joyce12, Bruce M Clark13, Robert A Colbert1, Mark P Figgie14, David S Hallegua15, Pamela E Prete16, James T Rosenbaum17, Judith A Stebulis18, Filip van den Bosch19, David T Y Yu20, Amy S Miller12, John D Reveille21, Liron Caplan22. 1. National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland. 2. Oregon Health & Science University, Portland. 3. American University of Beirut, Beirut, Lebanon, and McMaster University, Hamilton, Ontario, Canada. 4. University of California, San Francisco. 5. Brigham and Women's Hospital, Boston, Massachusetts. 6. University of Wisconsin, Madison. 7. Arthritis and Rheumatism Associates, Washington, DC. 8. Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia. 9. University of Toronto, Toronto, Ontario, Canada. 10. University of Mississippi Medical Center, Jackson. 11. University of Alberta, Edmonton, Alberta, Canada. 12. American College of Rheumatology, Atlanta, Georgia. 13. Vancouver, British Columbia, Canada. 14. Hospital for Special Surgery, New York, New York. 15. Cedars-Sinai Medical Center, Beverly Hills, California. 16. VA Long Beach Medical Center, Long Beach, California, and University of California, Irvine. 17. Oregon Health & Science University and Legacy Devers Eye Institute, Portland. 18. University of Massachusetts, Worcester. 19. University of Ghent, Ghent, Belgium. 20. University of California, Los Angeles. 21. University of Texas Health Sciences Center at Houston. 22. Denver VA Medical Center, Denver, Colorado, and University of Colorado, Aurora.
Abstract
OBJECTIVE: To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. RESULTS: In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS. CONCLUSION: These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.
OBJECTIVE: To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. RESULTS: In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS. CONCLUSION: These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.
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