American College of Rheumatology guidelines for the treatment of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) have been updated with new information, including the management of biologics and their biosimilars.

The update was based on a systematic literature review for 20 clinical questions on drug treatment addressed in the previous 2015 guidelines along with 26 new questions on pharmacological treatment, a treat-to-target strategy and the use of imaging.

Lead investigator of the guidelines, Dr Michael Ward from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, said the update would help patients receive effective treatment faster.

“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,” he said.

Some of the major changes include:

• Sulfasalazine and pamidronate were previously suggested as alternatives for the treatment of patients with active disease and contraindications to TNFi. The new 2019 recommendations suggest use of secukinumab or ixekizumab in most of these cases, except patients with high risk of infections.
• In cases of failure of TNFi, the 2015 guidelines included a conditional recommendation for a trial of a second TNFi and against use of a non-TNFi biologic. The new guidelines differentiate treatment recommendations based on whether there was primary or secondary nonresponse to the TNFi.
• Advice on the treatment of patients with recurrent uveitis, has broadened from conditional use of infliximab or adalimumab, to include TNFi monoclonal antibodies generally.
• For patients with coexisting IBD, the update includes a conditional recommendation for TNFi monoclonal antibodies over other biologics, rather than over only etanercept.
• The recommendation for use of TNFi in patients with active nonradiographic axial SpA was changed from conditional to strong.

In one of the new clinical questions regarding treatment of patients with stable disease, discontinuation of biologics was not recommended due to the likelihood for symptom recurrence. If tapering is considered, patients should be counselled regarding the potential for increased disease activity.

The guidelines also said that co-treatment with low-dose methotrexate is not generally recommended, however “ongoing studies will shed further light on this question”.

Switching to a biosimilar during the course of treatment with TNFi was also not recommended, echoing the concerns expressed by the ACR in a 2018 position statement.