What are the guideline sources, guidelines and references for Ankylosing spondylitis ?
Guideline sources The following summarized guidelines for the evaluation and management of ankylosing spondylitis (AS) are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023), the Assessment of SpondyloArthritis international Society (ASAS/EULAR 2022), the European League Against Rheumatism (EULAR 2022), the American College of Radiology (ACR 2021; 2017), the Spondyloarthritis Research and Treatment Network (SPARTAN/ACR/SAA 2019), and the British Society for Rheumatology (BSR/BHPR 2017). 1 2 3 4 5 6 7 8 8 8 9 10 11 Definition AS is a chronic inflammatory disease characterized by arthritis of the spine and the sacroiliac joints. 8 Epidemiology https://web.pathway.md/diseases/recBFY65QPWugVBdu 1/9 6/23/23, 2:36 AM Ankylosing spondylitis Pathway AS is strongly associated with the HLA-B27 genotype, although most persons with this genotype do not develop the disease. The etiology of joint inflammation in patients with AS involves the interaction of genetic predisposition and environmental factors with alterations in immune cell function, and cytokine regulation. 8 10 Pathophysiology In the United States, the annual incidence and prevalence of AS are 3.1 cases per 100,000 person- years and 197 persons per 100,000 population, respectively. 9 Disease course Clinical manifestations of AS include arthritis, dactylitis, ankylosis, osteoporosis of the spine and peripheral bones, uveitis, and IBD. 8 Prognosis and risk of recurrence Patients with AS have an increased risk of mortality, with an estimated standardized mortality ratio of 1.61. CVD is the most frequent cause of death (40%), followed by malignant (27%) and infectious (23%) diseases. 11 Guidelines 1. Classification and risk stratification Severity assessment: measure BASDAI on 2 occasions at least 4 weeks apart. B Define the disease as active if BASDAI and spinal pain Visual Analogue Scale score is 4 despite standard therapy. B 2. Diagnostic investigations Diagnostic imaging: As per ACR 2021 guidelines, obtain radiography of sacroiliac joints or sacroiliac joints and spine area of interest as the initial imaging of suspected axial spondyloarthritis. B Show 3 more As per ACR 2017 guidelines: Obtain radiography (often showing characteristic osseous findings) as initial imaging in patients with suspected seronegative spondyloarthropathy. E Obtain ultrasound or MRI to complement radiography by showing synovitis and identifying additional erosions. E Screening for osteoporosis: Consider screening for osteopenia/osteoporosis with dual X-ray absorptiometry. C https://web.pathway.md/diseases/recBFY65QPWugVBdu 2/9 6/23/23, 2:36 AM Ankylosing spondylitis Pathway Consider screening for osteoporosis/osteopenia with dual X-ray absorptiometry of the spine and hips over dual X-ray absorptiometry solely of the hip or other non-spine sites in adult patients with syndesmophytes or spinal fusion. C Screening for heart diseases: do not screen for cardiac conduction defects (with ECG) or VHDs (with echocardiogram). D Screening for chronic infections: screen for HBV infection in all patients eligible for treatment with conventional synthetic, biological, or targeted synthetic DMARDs, immunosuppressants, or corticosteroids (according to dose and duration). B Show 3 more 3. Medical management General principles: As per ASAS 2022 guidelines, individualize treatment of patients with axial spondyloarthritis according to the current signs and symptoms of the disease (axial, peripheral, extra- musculoskeletal manifestations) and the patient characteristics including comorbidities and psychosocial factors. Guide treatment according to a predefined treatment target. E As per ACR 2019 guidelines, avoid using a treat-to-target strategy with a target of ASDAS < 1.3 (or 2.1) over a treatment strategy based on physician assessment in adult patients with active AS. D Management of active AS, NSAIDs: As per EULAR/ASAS 2022 guidelines, initiate NSAIDs up to the maximum dose as first-line pharmacotherapy, taking risks and benefits into account, in patients experiencing pain and stiffness. Continue treatment if needed to control symptoms in patients responding well to NSAIDs. E As per SPARTAN/SAA/ACR 2019 guidelines: Initiate NSAIDs in adult patients with AS. B Consider preferring continuous over on-demand treatment with NSAIDs. B Insufficient evidence to recommend any particular NSAID as the preferred choice. I Landmark trials: PRECISION In patients at increased cardiovascular risk in whom NSAIDs were indicated for OA or rheumatoid arthritis, celecoxib was noninferior to ibuprofen or naproxen with regard to cardiovascular safety. The risk of gastrointestinal events was significantly lower with celecoxib than with naproxen and ibuprofen, and the risk of renal events was significantly lower with celecoxib than with ibuprofen. Nissen SE et al. N Engl J Med. 2016 Dec 29. Management of active AS, DMARDs: https://web.pathway.md/diseases/recBFY65QPWugVBdu 3/9 6/23/23, 2:36 AM Ankylosing spondylitis Pathway As per EULAR/ASAS 2022 guidelines, avoid using conventional synthetic DMARDs in patients with purely axial disease. Consider initiating sulfasalazine in patients with peripheral arthritis. D As per SPARTAN/SAA/ACR 2019 guidelines, consider initiating sulfasalazine, methotrexate, or tofacitinib in adult patients with active AS despite treatment with NSAIDs. Consider initiating sulfasalazine or methotrexate only in patients with prominent peripheral arthritis or when TNF inhibitors are not available. C Show 2 more Management of active AS, biologic agents: As per EULAR/ASAS 2022 guidelines, consider initiating TNF inhibitors, IL-17 inhibitors, or JAK inhibitors in patients with persistently high disease activity despite conventional treatments. E Show 3 more As per SPARTAN/SAA/ACR 2019 guidelines, consider initiating TNF inhibitors over tofacitinib in adult patients with active AS despite treatment with NSAIDs. C Show 9 more As per BHPR/BSR 2017 guidelines, verify that worsening symptoms, radiological changes, and raised inflammatory markers are due to axial spondyloarthritis and not due to other pathologies, such as malignancy or infection, before initiating biologic treatment. B Show 6 more Management of active AS, corticosteroids: As per EULAR/ASAS 2022 guidelines, do not use long-term systemic corticosteroids in patients with axial disease. D As per SPARTAN/SAA/ACR 2019 guidelines, do not use systemic corticosteroids in adult patients with active AS. D Management of stable AS: As per EULAR 2022 guidelines, consider tapering biological DMARDs in patients with sustained remission. E As per ACR 2019 guidelines, consider prescribing on-demand over continuous NSAIDs in patients with stable AS. C Show 6 more Management of pain: Initiate NSAIDs up to the maximum dose as first-line pharmacotherapy, taking risks and benefits into account, in patients experiencing pain and stiffness. Continue treatment if needed to control symptoms in patients responding well to NSAIDs. E Consider initiating analgesics, such as acetaminophen and opioid-(like) drugs, for residual pain after previously recommended treatments have failed, are contraindicated, and/or poorly tolerated. E Management of uveitis: As per ASAS 2022 guidelines, prefer monoclonal antibodies against TNF in patients with a history of recurrent uveitis. E https://web.pathway.md/diseases/recBFY65QPWugVBdu 4/9 6/23/23, 2:36 AM Ankylosing spondylitis Pathway As per ACR 2019 guidelines, treat adult patients with acute iritis by an ophthalmologist to decrease the severity, duration or complications of episodes. B Show 2 more 4. Nonpharmacologic interventions Smoking cessation: advise smoking cessation in patients with AS. E Physical therapy: As per ASAS 2022 guidelines, encourage patients with AS to exercise on a regular basis. Consider offering physical therapy. E As per ACR 2019 guidelines, offer physical therapy in adult patients with active AS. B Show 4 more Spinal manipulation: do not offer spinal manipulation in adult patients with spinal fusion or advanced spinal osteoporosis. D 5. Therapeutic procedures Local corticosteroid injections: As per ASAS 2022 guidelines, consider administering corticosteroid injections directed to the local site of musculoskeletal inflammation. E As per ACR 2019 guidelines, consider administering local parenteral corticosteroids in adult patients with isolated active sacroiliitis despite treatment with NSAIDs. C Show 2 more 6. Surgical interventions Spinal osteotomy: As per EULAR 2022 guidelines, consider performing spinal corrective osteotomy in patients with severe disabling deformity in specialized centers. E As per ACR 2019 guidelines, avoid performing elective spinal osteotomy in adult patients with severe kyphosis. D Total hip replacement: As per ASAS 2022 guidelines, consider performing total hip arthroplasty in patients with refractory pain or disability and radiographic evidence of structural damage, irrespective of age. E As per ACR 2019 guidelines, perform total hip arthroplasty in adult patients with advanced hip arthritis. B https://web.pathway.md/diseases/recBFY65QPWugVBdu 5/9 6/23/23, 2:36 AM Ankylosing spondylitis Pathway 7. Specific circumstances Patients with inflammatory bowel disease: As per ASAS 2022 guidelines, prefer monoclonal antibodies against TNF in patients with active IBD. E As per ACR 2019 guidelines: Insufficient evidence to recommend any particular NSAID as the preferred choice to decrease the risk of worsening of IBD symptoms in adult patients with IBD. I Consider initiating TNF inhibitor monoclonal antibodies over other biologic agents in adult patients with IBD. C 8. Patient education General counseling: As per ASAS 2022 guidelines, educate patients with axial spondyloarthritis about their condition. E As per ACR 2019 guidelines: Consider advising participation in formal group or individual self-management education in adult patients with active or stable AS. C Consider obtaining fall evaluation and counseling in adult patients with active or stable AS. C 9. Preventative measures Routine immunizations: consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications. C Show 17 more Prophylaxis for Pneumocystis jirovecii pneumonia: consider administering prophylaxis against P. jirovecii pneumonia in patients initiating high-dose corticosteroids, especially in combination with immunosuppressants and depending on the risk-benefit ratio. C 10. Follow-up and surveillance Monitoring of disease activity: As per ASAS 2022 guidelines, assess patient-reported outcomes and clinical findings, obtain laboratory tests and imaging, all with the appropriate instruments and relevant to the clinical presentation, for disease monitoring of patients with axial spondyloarthritis. Decide on the frequency of monitoring on an individual basis depending on symptoms, severity, and treatment. E https://web.pathway.md/diseases/recBFY65QPWugVBdu 6/9 6/23/23, 2:36 AM Ankylosing spondylitis Pathway As per ACR 2021 guidelines, obtain radiography of sacroiliac joints +/- spine area of interest as the follow-up imaging for treatment response or disease progression in patients with axial spondyloarthritis. B As per ACR 2019 guidelines, consider obtaining a validated AS disease activity measurement for regular-interval use and monitoring. C Show 4 more Assessment of treatment response: As per ASAS 2022 guidelines: Obtain prompt re-evaluation of the diagnosis in the absence of treatment response and take into consideration the presence of comorbidities. E Suspect causes other than inflammation, such as spinal fracture, and obtain an appropriate evaluation, including imaging, if a significant change in the course of the disease occurs. E As per BSR 2017 guidelines, assess initial efficacy response following 3-6 months of anti-TNF therapy and reassess it every 6 months thereafter. B Show 2 more Likelihood Ratios Pertinent positives The following findings increase the probability of ankylosing spondylitis in adults. -1 Finding LR+ Value Presence of sacroiliitis 9.0 Presence of HLA-B27 9.0 Presence of anterior uveitis 7.3 History of alternating buttock pain 4.0 Show 4 more Pertinent negatives The following findings decrease the probability of ankylosing spondylitis in adults. -1 Finding LR- Value Absence of HLA-B27 0.1 Absence of sacroiliitis 0.1 No history of inflammatory back pain 0.3 serum CRP not increased 0.6 Show 4 more References https://web.pathway.md/diseases/recBFY65QPWugVBdu 7/9 6/23/23, 2:36 AM Ankylosing spondylitis Pathway 1. Sofia Ramiro, Elena Nikiphorou, Alexandre Sepriano et al. ASAS EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis. 2022 Oct 21;ard-2022 223296. Open 2. Michael M Ward, Atul Deodhar, Lianne S Gensler et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019 Oct;71 10 1599 1613. Open 3. George E Fragoulis, Elena Nikiphorou, Mrinalini Dey et al. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2022 Nov 3;ard-2022 223335. Open 4. Hamilton L, Barkham N, Bhalla A et al. BSR and BHPR guideline for the treatment of axial spondyloarthritis (including ankylosing spondylitis) with biologics. Rheumatology Oxford). 2017 Feb;56 2 313 316. Open 5. Expert Panel on Musculoskeletal Imaging, Gregory J Czuczman, Jacob C Mandell et al. ACR Appropriateness Criteria Inflammatory Back Pain: Known or Suspected Axial Spondyloarthritis: 2021 Update. J Am Coll Radiol. 2021 Nov;18 11S S340 S360. Open 6. Anne R Bass, Eliza Chakravarty, Elie A Akl et al. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol. 2023 Jan 4. Online ahead of print. Open 7. Expert Panel on Musculoskeletal Imaging:, Jon A Jacobson, Catherine C Roberts et al. ACR Appropriateness Criteria Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis. J Am Coll Radiol. 2017 May;14 5S S81 S89. Open 8. Taurog JD, Chhabra A, Colbert RA. Ankylosing Spondylitis and Axial Spondyloarthritis. N Engl J Med. 2016 Jun 30;374 26 2563 74. Open 9. Wright KA, Crowson CS, Michet CJ et al. Time trends in incidence, clinical features, and cardiovascular disease in ankylosing spondylitis over three decades: a population-based study. Arthritis Care Res Hoboken). 2015 May;67 6 836 41. Open 10. Tsui FW, Tsui HW, Akram A et al. The genetic basis of ankylosing spondylitis: new insights into disease pathogenesis. Appl Clin Genet. 2014 May 22;7 105 15. Open 11. Bakland G, Gran JT, Nossent JC. Increased mortality in ankylosing spondylitis is related to disease activity. Ann Rheum Dis. 2011 Nov;70 11 1921 5. Open 12. Ward MM, Deodhar A, Akl EA et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2016 Feb;68 2 282 98. Open 13. D sir e van der Heijde, Sofia Ramiro, Robert Landew et al. 2016 update of the ASAS EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017 Jun;76 6 978 991. Open 14. P Mandl, V Navarro-Comp n, L Terslev et al. EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis. 2015 Jul;74 7 1327 39. Open https://web.pathway.md/diseases/recBFY65QPWugVBdu 8/9 6/23/23, 2:36 AM Ankylosing spondylitis Pathway https://web.pathway.md/diseases/recBFY65QPWugVBdu 9/9