Spondyloarthritis

EULAR publishes new guidelines for SpA


A joint taskforce made up of members from the Assessment of Spondyloarthritis International Society (ASAS) and EULAR have issued joint recommendations for managing patients with axial SpA.

The guidelines update ones published by the two groups in 2011. You can check out the 13 specific recommendations below.

  1. Treatment: The treatment of patients with axSpa should be individualised according to the signs and symptoms of the disease including co-morbidities and psychosocial factors (level of evidence of 4, high level of agreement).
  1. Disease monitoring: The disease monitoring of patients with axial SpA should include patient reported outcomes, clinical findings, laboratory tests and imaging all with appropriate instruments and relevant to the clinical presentation. The frequency of monitoring should be decided on an individual basis depending on symptoms, severity and treatment. (level of evidence 4, but high agreement).
  1. Treatment targets. Treatment target should be guided according to a predefined treatment target (level of evidence 4).
  1. Non-pharmacological therapy: Patients should be educated about axSpA and encouraged to exercise on a regular basis and stop smoking; physical therapy should be considered (level of evidence for education and exercise 2; physical therapy 1a; stop smoking 4).
  1. NSAIDS. Patients with pain and stiffness should use an NSAID as first line drug treatment for up to the maximum dose, taking risks and benefits into account. For patients who respond well to NSAIDs continuous use is preferred if symptomatic otherwise (Level of evidence 1a).
  1. Other analgesics: Paracetamol and opioid (like) drugs might be considered for residual pain after previously recommended treatments have either failed or are contraindicated (Level of evidence 4).
  1. Corticosteroids: Glucocorticoid injections directed to the local site of musculoskeletal inflammation may be considered (Level of evidence 2). Patients with axial disease should not receive long-term treatment with systemic glucocorticoids (Level of evidence 4).
  1. DMARDS: Patients with purely axial disease should normally not be treated with csDMARDs. Sulfasalazine may be considered in patients with peripheral arthritis (Level of evidence 1b for sulfasalazine, MTX and leflunomide; level of evidence 4 for csDMARDs).
  1. Biological therapy: bDMARDS should be considered in patients with persistently high disease activity despite conventional treatments; current practice is to start with TNFi therapy (Level of evidence TNFi 1a; IL-17i 1b).
  1. TNFi failure. If TNFi therapy fails switching to another TNFi or IL17i therapy should be considered (level of evidence 2 for switching to another TNFi, level of evidence 1b for switching to IL-17i).
  1. Discontinuation of bDMARDs is reworded as continuation: clinicians should consider continuing bDMARDs if after at least 12 weeks of treatment there is an ASDAS improvement of ≥1.1 or BASDAI improvement of ≥ 2 and a positive rheumatologist’s opinion to continue.
  1. Surgery: Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age; spinal corrective osteotomy in specialised centres may be considered in patients with severe disabling deformity (Level of evidence 3).
  1. Changes in the disease course: If a significant change in the course of the disease occurs, causes other than inflammation, such as a spinal fracture, should be considered and appropriate evaluation, including imaging, should be performed (level of evidence 4).

*1a indicates a high level of evidence, level 4 indicates expert opinion.

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