1. Slide set should, if possible, not exceed 20 Slides
2016 update of the ASAS-EULAR management recommendations for axial SpondyloArthritis

2. Slide 1: Target population/question
Health care professionals taking care of patients with axSpA
Patients to be educated for informed shared decision-making
Pharmaceutical industry, drug agencies, policy makers, health insurance companies
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3. Methods/methodical approach
2 Systematic literature reviews (SLRs) since 2009
non-pharmacological treatment (Andrea Regel)
pharmacological treatment (Alexandre Sepriano)
SLR on the use of ASDAS vs. BASDAI to define disease activity for the start and continuation of bDMARDs
One-day meeting of the task force
presentation of the findings of the SLRs
rewording of 2010 overarching principles and recommendations
new recommendations formulated
voting on each new overarching principle/recommendation by all task force members in maximal 3 rounds (first round ≥75%, second round ≥67%, third round ≥50%)
After the meeting
Addition of the level of evidence for each recommendation (LoE) and Grade of Recommendation
Addition of level of agreement by the task force members by anonymous voting from 0 (I do not agree at all) to 10 (I fully agree) (LoA, mean (SD), %≥8)
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4. Overarching prinicples
Axial Spondyloarthritis (axSpA) is a potentially severe disease with diverse manifestations, usually requiring multidisciplinary management coordinated by the rheumatologist.
The primary goal of treating the patient with axSpA is to maximize health related quality of life through control of symptoms and inflammation, prevention of progressive structural damage, preservation/normalisation of function and social participation.
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5. Overarching prinicples
The optimal management of patients with axSpA requires a combination of non-pharmacological and pharmacological treatment modalities
Treatment of axSpA should aim at the best care and must be based on a shared decision between the patient and the rheumatologist
axSpA incurs high individual, medical and societal costs, all of which should be considered in its management by the treating rheumatologist
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6. Recommendation 1: General treatment
The treatment of patients with axSpA should be individualised according to the current signs and symptoms of the disease (axial, peripheral, extra-articular manifestations) and the patient characteristics including comorbidities and psychosocial factors.
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7. Recommendation 2: Disease monitoring
Disease monitoring of patients with axSpA should include patient reported outcomes, clinical findings, laboratory tests and imaging, all with the 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
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8. Recommendation 3: Treatment target
Treatment should be guided according to a predefined treatment target
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9. Recommendation 4: 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
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10. Recommendation 5: NSAIDs
Patients suffering from pain and stiffness should use an NSAID as first line drug treatment 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
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11. Recommendation 6: Analgesics
Analgesics, such as paracetamol and opioid-(like) drugs, might be considered for residual pain after previously recommended treatments have failed, are contraindicated, and/or poorly tolerated
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12. Recommendation 7: Corticosteroids
Glucocorticoid injections directed to the local site of musculoskeletal inflammation may be considered
Patients with axial disease should not receive long-term treatment with systemic glucocorticoids
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13. Recommendation 8: DMARDs
Patients with purely axial disease should normally not be treated with csDMARDs
Sulfasalazine may be considered in patients with peripheral arthritis
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14. Recommendation 9: Biological therapy
bDMARDs should be considered in patients with persistently high disease activity despite conventional treatments (box1)
Current practice is to start with TNFi therapy
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15. Rheumatologist’s diagnosis of axial SpA
ASAS-EULAR Recommendations for the Treatment of axSpA Patients with bDMARDs (box 1)
Rheumatologist’s diagnosis of axial SpA
Failure of standard treatment:
all patients
at least 2 NSAIDs over 4 weeks (in total)
patients with predominant peripheral manifestations
one local steroid injection if appropriate
normally a therapeutic trial of sulfasalazine
High disease activity: ASDAS ≥ 2.1 or BASDAI ≥ 4
Positive rheumatologist’s opinion
and
Elevated CRP and/or positive MRI and/or Radiographic sacroiliitis
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16. ASAS-EULAR Recommendations for the continuation of bDMARDs
ASDAS improvement ≥ 1.1 or
BASDAI improvement ≥ 2 (0-10)
and
Positive
rheumatologist‘s opinion to continue
Consider to continue bDMARDs if after at least 12 weeks of treatment
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17. Recommendation 10: TNFi failure
If TNFi therapy fails, switching to another TNFi or IL17i therapy should be considered
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18. Recommendation 11: bDMARD tapering
If a patient is in sustained remission, tapering of a bDMARD can be considered
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19. Recommendation 12: 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
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20. Recommendation 13: 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
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21. Oxford table 07/04/2019 Overarching principles LoE GoR LoA 1
9.9 (0.31) 100% ≥8 2
9.8 (0.47) 100% ≥8 3
9.8 (0.45) 100% ≥8 4
9.5 (0.91) 100% ≥8 5
9.3 (1.17) 97% ≥8
Recommendations D
9.7 (0.65) 100% ≥8
9.6 (0.78) 100% ≥8
Treatment should be guided according to a predefined treatment target.
8.9 (1.45) 93% ≥8
Patients should be educated* about axSpA and encouraged to exercise* on a regular basis and stop smoking#; physical therapy^ should be considered.
*2 ^1a #5
*B ^A #D
Patients suffering from pain and stiffness should use an NSAID as first line drug treatment 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. 1a A
9.4 (0.94) 100% ≥8 6
Analgesics, such as paracetamol and opioid-(like) drugs, might be considered for residual pain after previously recommended treatments have failed, are contraindicated, and/or poorly tolerated.
8.8 (0.94) 100% ≥8 7
Glucocorticoid injections* directed to the local site of musculoskeletal inflammation may be considered. Patients with axial disease should not receive long-term treatment with systemic glucocorticoids#.
*2 #5
*B #D
9.4 (0.78) 100% ≥8 8
Patients with purely axial disease should normally not be treated with csDMARDs1; Sulfasalazine^ may be considered in patients with peripheral arthritis.
^1a
9.2 (0.78) 100% ≥8 9
bDMARDs should be considered in patients with persistently high disease activity despite conventional treatments (box1); current practice is to start with TNFi therapy
1a (TNFi); 1b (IL17i)
9.6 (1.09) 93% ≥8 10
If TNFi therapy fails, switching to another TNFi* or IL17i” therapy should be considered.
*2 “1b
*B “A
9.6 (0.95) 97% ≥8 11
If a patient is in sustained remission, tapering of a bDMARD can be considered. B
9.1 (1.57) 97% ≥8 12
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 C
9.4 (0.82) 100% ≥8 13
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.
9.9 (0.31) 97% ≥8
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22. Summary of Recommendations
2016 management recommendations
are better worded as recommendations
integrate the previous management and TNFi-therapy recommendations
cover the entire spectrum of axSpA
emphasize the usefulness of nonpharmacological management
NSAIDs remain the first-line drug
starting of bDMARDs is integrated for patients with radiographic and nonradiographic axSpA
ASDAS as well as BASDAI can be used as disease activity measure
discontinuation of bDMARDs is reworded as continuation
TNFi therapy is the currently preferred bDMARD
after failure of TNFi therapy a switch to either a second TNFi or IL17i therapy is recommended
tapering of bDMARDs is included in the recommendations
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23. Summary of Recommendations in Lay format
07/04/201907/04/201907/04/201907/04/201907/04/201907/04/201907/04/201907/04/201907/04/201907/04/2019
Summary of Recommendations in Lay format
The new ASAS-EULAR recommendations are applicable to all patients with axial SpondyloArthritis (axSpA). This includes patients with nonradiographic axSpA (normal joints on the pelvis radiograph) and patients with radiographic axSpA (with abnormalities on the pelvis radiographs).
There are five overarching principles dealing with good practice such as
Optimal treatment requires a combination of non-pharmacological and pharmacological treatment modalities
shared decision making
The primary goal of treating the patient with axSpA is to maximize health related quality of life. This should be done by control of symptoms and inflammation, prevention of progressive structural damage, preservation/normalisation of function and social participation.
Thirteen recommendations are formulated
The first three deal with individualised treatment based on current signs and symptoms and patient characteristics; disease monitoring; and the definition of a treatment target.
The next five recommendations describe the use of non-pharmacological treatment, anti-inflammatory painkillers (‘NSAIDs’), painkillers, corticosteroids and other nonbiological antirheumatic drugs.
Only non-pharmacological management and NSAIDs play an important role in the treatment of axSpA.

24. Summary of Recommendations in Lay format
07/04/201907/04/201907/04/201907/04/201907/04/201907/04/201907/04/201907/04/201907/04/201907/04/2019
Summary of Recommendations in Lay format
Recommendations 9-11 describe the use of biological antirheumatic drugs. These are prescribed when there is persistent high disease activity despite other treatment. Also the continuation in full dose and possibly tapering is discussed.
The final two recommendations are on surgery and unexpected changes in the disease course.

25. Acknowledgements Steering committee Additional task force members
Victoria Navarro-Compán
Salih Özgöcmen
Fernando Pimentel dos Santos
John Reveille
Martin Rudwaleit
Percival Sampaio-Barros
Jochen Sieper
Irene van der Horst-Bruinsma
Floris van Gaalen
Dieter Wiek (PP)
Steering committee
Désirée van der Heijde (convenor)
Jürgen Braun (co- convenor)
Sofia Ramiro (methodologist)
Alexandre Sepriano (fellow)
Andrea Regel (fellow)
Xenofon Baraliakos
Robert Landewé
Filip van den Bosch
Additional task force members
Adrian Ciurea
Hanne Dagfinrud (HP)
Maxime Dougados
Pál Géher
Robert Inman
Merryn Jongkees (PP)
Uta Kiltz
Tore Kvien
Pedro Machado
Helena Marzo-Ortega
Anna Moltó
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