AxSpA Recommendations Address Specific Clinical Scenarios

The care of patients with axial spondyloarthritis (axSpA) should be holistic, individualized, and take into account objective findings, comorbidities, and patient preferences, advises a set of expert recommendations published in Rheumatology and Therapy.

The recommendations are intended to complement current guidelines, the authors wrote, and focus on controversial areas and guidance gaps. In addition to broad principles the experts believe should underlie all axSpA treatment, such as the use of validated tools for patient monitoring, the recommendations address musculoskeletal manifestations, extramusculoskeletal manifestations, comorbidity, risk management, and treatment.  

For musculoskeletal manifestations, the statements advise:

• a history and exhaustive physical exam in patients with enthesitis to rule out mechanical pain or other problems;
• tumor necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i), or Janus kinase inhibitors (JAKi) in patients with refractory enthesitis;
• conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) before TNFi, IL-17i, and JAKi in patients with stable axial disease and active peripheral arthritis/tenosynovitis/dactylitis; and
• no contraindication for biologic and targeted synthetic DMARDs (b/tsDMARDs) in patients with significant structural damage.

Forr extramusculoskeletal manifestations, the statements advise:

• decision-making with the patient’s specialist or health professional;
• monoclonal antibodies against TNFα in patients with recurrent noninfectious uveitis refractory to csDMARDs; and
• monoclonal antibodies against TNFα or JAKi in patients with coexistent inflammatory bowel disease.

Comorbidity statements advise:

• systematic comorbidity screening and management in all patients;
• evaluation of cardiovascular risk;
• the lowest effective nonsteroidal anti-inflammatory drug (NSAID) dose for the shortest time possible in patients with cardiovascular disease or risk for whom NSAIDs are essential;

Risk management statements advise:

• assessment of risk factors for infection in patients using b/tsDMARDs; and
• the need to follow product and scientific societies’ risk management recommendations for patients using NSAIDs, corticosteroids, csDMARDs, and b/tsDMARDs.

Finally, treatment-related statements advise:

• no contraindication for b/tsDMARDs with human leukocyte antigen B27 (HLA-B27)-negative status;
• that the absence of objective markers of inflammation does not signal a lack of response or a need to avoid using b/tsDMARDs;
• an early treatment strategy;
• the need for more action and strategies to guarantee early diagnosis and treatment; and
• treatment regardless of disease duration.

“Treatment decisions are not always straightforward in axSpA,” wrote corresponding study author Rosario García-Vicuña, MD, PhD, of Hospital Universitario La Princesa, in Madrid, Spain, and coauthors. “We have proposed overarching principles and recommendations for the management of axSpA patients regarding difficult-to-treat clinical scenarios or controversial areas, based on the best evidence available and the opinion of an expert panel.”

Reference

García-Vicuña R, Juanola X, Navarro-Compán V, et al. Management of specific clinical profiles in axial spondyloarthritis: an expert's document based on a systematic literature review and extended Delphi process. Rheumatol Ther. 2023;10(5):1215-1240.

doi:10.1007/s40744-023-00575-9