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Updated Medication and Imaging Guidelines for Managing Axial Spondyloarthritis

NSAIDs and TNF inhibitors remain primary medications for AS, but secukinumab and ixekizumab are also now noted.

with Michael Ward, MD, MPH, and 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 nonradiographic axial spondyloarthritis in 2019.1

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 nonradiographic axial spondyloarthritis.2 Both subtypes of axial spondyloarthritis are similar to each other; however, a defining difference is the absence of spine ankylosis and advanced sacroiliac joint damage in nonradiographic axial spondyloarthritis.3

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.1

“[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,” Michael Ward, MD, MPH, researcher at the National Institute of Arthritis and Musculoskeletal and Skin Diseases and lead author of the publication, told PPM.

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.

The ACR has made an update to their evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA) (Image: iStockPhoto)

Developing the Latest Set of Recommendations

The committee conducted systematic literature reviews on 20 questions from the previous guidelines, as well as 26 additional questions, all questions generated using the prespecified clinical population, intervention, comparator, outcomes (PICO) approach. Upon review of the available evidence, recommendations were formulated, on which a panel of experts voted. All recommendations were evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method, which includes a ranking system of recommendations based on the quality of available evidence.

Biological Antibodies, TNF Inhibitors, and Radiographic Imaging

In discussion with PPM, Dr. Ward highlighted some important clinical pearls from the updated guidelines:

  • Non-steroidal anti-inflammatory drugs (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 magnetic resonance imaging (MRI) may be used when the degree of spondylitis activity is unclear and when detection of inflammation would lead to change in treatment.

Secukinumab (Cosentyx; Novartis) was approved by FDA for treatment of ankylosing spondylitis in August 2016,5 and ixekizumab (Taltz; Eli Lilly and Company) was FDA-approved in August 2019.6 Both drugs are biological antibodies that interfere with the action of interleukin-17A cytokines, which play a role in inflammation.4,5,6

“TNF inhibitors have been demonstrated to be effective in treating both active ankylosing spondylitisand nonradiographic 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. “[T]he 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.”

Radiographic imaging continues to play a crucial role as a diagnostic tool for both ankylosing spondylitis and nonradiographic axial spondyloarthritis.1 The 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.

Conclusions, Limitations and Future Directions

“It appears that based on the systematic review, there is reason to expect that TNFi medication can improve symptoms and overall function in this patient population,” 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, commented regarding the new guideline update.“For 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,” Dr. Marovino elaborated.

The ACR, SAA, and SPARTAN note that an important limitation to the recommendations is the quality of available evidence. The panel relied heavily on clinical expertise in compiling these recommendations. “Key evidence gaps include the comparative effectiveness and safety of different biologics, the optimal sequencing of treatments, and the role of NSAIDs,” the authors wrote in their publication. “As more treatment options become available, this problem will grow.”

The ACR, SAA, and SPARTAN also noted that the recommendations were generalized to typical cases, but treatment of patients with these conditions requires an individualized approach.1

“Given the expanding scope of medications, it is best to engage with a rheumatologist for patients whose symptoms are not adequately controlled with exercise and NSAIDs,” Dr. Ward suggested. 

Last updated on: December 16, 2019
Continue Reading:
Sacroiliac Joint Dysfunction: New Methods in Evaluation and Management
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