ACR releases new recommendations for treatment of AS and non-radiographic axial SpA

The American College of Rheumatology (ACR) has released new recommendations for the treatment of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (SpA). The guideline was developed with the Spondylitis Association of America (SAA) and the Spondyloarthritis Research and Treatment Network. It summarizes recommendations for both pharmacologic and non-pharmacologic treatments, including rehabilitation, management of patients with comorbid conditions, use of certain surgeries and approaches to patient monitoring.

"The ACR's primary objective was to provide recommendations on optimal treatment for patients with AS and non-radiographic axial SpA that were based on quality evidence and took into consideration patient values and preferences," said Michael Ward, MD, MPH, an investigator for the National Institutes of Health who served as principal investigator for the guideline project. "While the guideline does not cover all aspects of spondyloarthritis management, it provides a foundation based on the current best-available evidence."

In addition to covering a broad spectrum of treatment options, the guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (called GRADE) approach - a system recognized for transparency and for rating both the quality of available evidence and the strength of recommendations made. Important features of this method include the specification of patient groups, interventions, competing treatment alternatives and outcomes; grading the quality of the evidence used; and basing recommendation strength on evidence quality, balance of benefits and harms, patient preference of treatment options, as well as clinical experience and expertise.

Each recommendation is designated as being strongly for, conditionally for, conditionally against, or strongly against. Recommendations that were strongly for a given treatment signified that almost all patients would choose to receive the intervention and clinicians could expect it to be accepted by most patients to whom it is offered. Recommendations that were conditionally for a specified treatment signified that most patients would likely choose the intervention, but a sizable majority may not, and education and shared decision-making should play a large role. On the opposite end, conditional recommendations in opposition to an intervention signified that only a small a minority of patients would choose it, and education and shared decision-making would be important. Finally, strong recommendations in opposition to a treatment option signified interventions that most patients should neither receive nor be offered.

The recommendations are divided into five categories:

•Recommendations for the treatment of patients with active AS (pharmacologic and rehabilitation)
•Recommendations for the treatment of patients with stable AS (pharmacologic and rehabilitation)
•Recommendations for the treatment of patients with either active or stable AS
•Recommendations for the treatment of patients with AS and specific impairments or comorbidities (such as advanced hip arthritis, severe kyphosis, acute iritis, and inflammatory bowel disease)
•Education and preventive care recommendations; and
•Recommendations for the treatment of patients with non-radiographic axial SpA.

Each category contains several recommendations pertaining to pharmacologic and non-pharmacologic interventions, followed by supporting evidence and rationale.