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19 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Axial Spondyloarthritis: Updated Medication and Imaging Recommendations

The ACR, SAA, and SPARTAN released new guidelines for managing ankylosing spondylitis and non-radiographic axial spondyloarthritis based on emerging research and an expansion of treatment options.
Page 44

with Tiziano Marovino, DPT, MPH, DAIPM

The American College of Rheumatology (ACR), Spondylitis Association of America (SAA), and the Spondyloarthritis Research and Treatment Network (SPARTAN) released updated guidelines on the management of ankylosing spondylitis and non-radiographic axial spondyloarthritis in 2019.1 Previous guidelines published in 2015 outlined evidence-based recommendations for the management of these conditions. However, emerging research has led to an expansion of treatment options, resulting in the publication of the latest update.

Axial spondyloarthritis is a chronic form of inflammatory arthritis that affects the axial skeleton, afflicting approximately 1% of adults in the United States. It has two sub-classifications: ankylosing spondylitis and non-radiographic axial spondyloarthritis.2 Both subtypes are similar to each other; however, a defining difference is the absence of spine ankylosis and advanced sacroiliac joint damage in non-radiographic axial spondyloarthritis.3

“[Many] medications were not available at the time of the initial 2015 ACR recommendations, and one of the motivations for this update was to incorporate new medications such as these in the recommendations,” explained Michael Ward, MD, MPH, researcher at the National Institute of Arthritis and Musculoskeletal and Skin Diseases and lead author of the publication. In addition to providing recommendations on how to incorporate newly available medications into treatment strategies, Dr. Ward and his team have updated best practices on the use of imaging in disease management.

Secukinumab and ixekizumab are now available as treatment options for patients with active ankylosing spondylitis, although TNFi should still be selected as the first biologic treatment. (Image: iStock)

TNF Inhibitors

“TNF inhibitors have been demonstrated to be effective in treating both active ankylosing spondylitis and non-radiographic axial spondyloarthritis. In these recommendations, NSAIDs were recommended to be the initial treatment, followed by TNF inhibitors for patients who did not respond,” Dr. Ward explained. “The committee recommended that TNF inhibitors be used as the first biologic treatment in patients with active AS despite NSAIDs, rather than secukinumab or ixekizumab, given the greater experience with TNF inhibitors.” He continued, “No specific TNF inhibitor was preferred, except for patients with coexisting inflammatory bowel disease or recurrent uveitis, in whom one of the TNF monoclonals should be used. Treatment with TNF inhibitors are likely needed long-term. Before starting treatment, screening for tuberculosis and fungal infections and assessment of risk of bacterial infections is important.”

Tiziano Marovino, DPT, MPH, DAIPM, chief of Health Strategy and Innovation at the Biogenesis Group in Ypsilanti, MI, and a member of PPM’s Editorial Advisory Board, also commented on the guideline update. “It appears that based on the systematic review, there is reason to expect that TNF inhibitor (TNFi) medication can improve symptoms and overall function in this patient population… or those patients with lower disease activity and using NSAIDs, there is no compelling reason to have to use continuous NSAIDs when intermittent or on-demand NSAIDs work equally well and minimize adverse effects.”

Dr. Marovino continued, “In patients with moderate to high disease activity, the delay in using TNFi may lead to earlier radiographic progression of the disease. The use of TNFi is not recommended as a standalone treatment; rather to be combined with exercise and nutrition strategies for the global management of autoimmune-induced spondyloarthropathies.”

Imaging

Radiographic imaging continues to play a crucial role as a diagnostic tool for both ankylosing spondylitis and non-radiographic axial spondyloarthritis.1 The new recommendations call for using a spine MRI when the degree of spondylitis activity is unclear and when detection of inflammation by MRI could lead to a change in treatment. The committee also recommended against routine scheduled spine radiographs to monitor the progression of spine fusion, Dr. Ward said.

Clinical Takeaways

Dr. Ward highlighted some important clinical pearls from the updated guidelines overall:

  • NSAIDs and tumor necrosis factor inhibitors (TNFi) remain the primary classes of medications for the treatment of axial spondyloarthritis.
  • Secukinumab and ixekizumab are now available as treatment options for patients with active ankylosing spondylitis, although TNFi should still be selected as the first biologic treatment.
  • Clinicians should exercise caution about tapering or discontinuing biologics when their patients are in remission, considering this option in selected patients only.
  • Routine scheduled spine radiographs are not recommended to monitor the progression of spine fusion.
  • Spine MRI may be used when the degree of spondylitis activity is unclear and when detection of inflammation would lead to change in treatment.

    The ACR, SAA, and SPARTAN note that an important limitation to the recommendations made is the quality of available evidence. The panel relied heavily on clinical expertise in compiling these recommendations. They also pointed out that the recommendations were generalized to typical cases while treatment of patients with these conditions requires an individualized approach.1 

Last updated on: August 3, 2020
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Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
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