ASAS-EULAR Recommendations for the Management of Axial Spondyloarthritis: 2022 Update

Sofia Ramiro¹, Elena Nikiphorou², Alexandre Sepriano³, Augusta Ortolan⁴, Casper Webers⁵, Xenofon Baraliakos⁶, Robert Landewé⁷, Filip Van den bosch⁸, Boryana Boteva⁹, Ann Bremander¹⁰, Philippe Carron¹¹, Adrian Ciurea¹², floris van Gaalen¹, Pal Geher¹³, Lianne Gensler¹⁴, Josef Hermann¹⁵, Manouk de Hooge¹⁶, Marketa Husakova¹⁷, Uta Kiltz¹⁸, Clementina Lopez-Medina¹⁹, Pedro Machado²⁰, Helena Marzo-Ortega²¹, Anna Molto²², Victoria Navarro-Compán²³, Michael Nissen²⁴, Fernando Pimentel-Santos²⁵, Denis Poddubnyy²⁶, Fabian Proft²⁶, Martin Rudwaleit²⁷, Mark Telkman⁹, Sizheng Zhao²⁸, Nelly Ziade²⁹ and Désirée van der Heijde³⁰, ¹Leiden University Medical Center, Leiden, Netherlands, ²Leiden University Medical Center & King's College London, London, United Kingdom, ³Leiden University Medical Centre, Portela Loures, Portugal, ⁴University of Padova/Leiden University Medical Center, Padova, Italy, ⁵Maastricht University Medical Centre, Maastricht, Netherlands, ⁶Rheumazentrum Ruhrgebiet Herne, Herne, Germany, ⁷Amsterdam University Medical Center, Meerssen, Netherlands, ⁸Department of Internal Medicine and Paediatrics, Ghent University and VIB Centre for Inflammation Research, Ghent, Belgium, ⁹Patients with Arthritis and Rheumatism (PARE) working group, EULAR, Zürich, Switzerland, ¹⁰Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark, ¹¹Ghent University Hospital, Ghent, Belgium, ¹²University Hospital Zurich, Zürich, Switzerland, ¹³Semmelweis University, Budapest, Hungary, ¹⁴Department of Medicine, Division of Rheumatology, University of California San Francisco, San Francisco, CA, ¹⁵Medical University of Graz, Graz, Austria, ¹⁶Ghent University Hospital, Luxembourg, Luxembourg, ¹⁷Department of Rheumatology, First Faculty of Medicine, Charles University and Rheumatology Institute, Prague, Prague, Czech Republic, ¹⁸Rheumazentrum Ruhrgebiet, Herne, Germany, ¹⁹Reina Sofia University Hospital, Rheumatology Department, Jaén, Spain, ²⁰University College London, London, United Kingdom, ²¹Leeds Teaching Hospitals Trust and University of Leeds, Leeds, United Kingdom, ²²Rheumatology Department, Hôpital Cochin,Assistance Publique- Hôpitaux de Paris, Paris, France, ²³Department of Rheumatology, La Paz University Hospital, IdiPaz, Madrid, Spain, ²⁴Hopitaux Universitaires de Genève, Geneva, Switzerland, ²⁵NOVA Medical School; Universidade NOVA e Lisboa, Lisboa, Portugal, ²⁶Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité – Universitätsmedizin Berlin, Berlin, Germany, ²⁷University of Bielefeld, Klinikum Bielefeld, Bielefeld; Germany Klinikum Bielefeld and Charité Berlin, Germany, and Gent University, Gent, Belgium, ²⁸University of Manchester, Liverpool, United Kingdom, ²⁹Saint-Joseph University, Beirut, Lebanon, ³⁰Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands, Leiden, Netherlands

Meeting: ACR Convergence 2022

Keywords: Biologicals, Disease-Modifying Antirheumatic Drugs (Dmards), spondyloarthritis

Session Information

Date: Saturday, November 12, 2022

Title: Abstracts: Spondyloarthritis Including PsA – Treatment I: Axial Spondyloarthritis

Session Type: Abstract Session

Session Time: 4:30PM-6:00PM

Background/Purpose: Since the last update of the ASAS-EULAR recommendations for the management of axial spondyloarthritis (axSpA) in 2016, substantial new evidence has become available on the management of axSpA. Our aim was to update the ASAS-EULAR recommendations for the management of axSpA.

Methods: Following the EULAR Standardised Operating Procedures, two systematic literature reviews were conducted on non-pharmacological and pharmacological treatment of axSpA. During a task force meeting the evidence was presented, discussed and overarching principles and recommendations were updated, followed by voting.

Results: A total of 5 overarching principles (unchanged compared to the previous version of the recommendations) and 15 recommendations were formulated (Table). All recommendations included in the previous version were kept: eight unchanged (#2,3,6,7,8,13,14,15); three with minor edits, mostly on nomenclature (#1,4,5) and two with relevant updates (#9,12), while two newly formulated recommendations (#10,11) were added. The first 5 recommendations focus on personalised medicine, including treatment target and monitoring, non-pharmacological management and non-steroidal anti-inflammatory drugs (NSAIDs) as first choice pharmacological treatment. Recommendations 6-8 deal with analgesics and discourage long-term glucocorticoids and conventional synthetic DMARDs for pure axial involvement. Recommendation 9 describes the indication for biological DMARDs (bDMARDs i.e. TNFi, IL-17i) and this was expanded to targeted synthetic DMARDs (tsDMARDs i.e. JAKi). b/tsDMARDs are indicated for patients with elevated CRP, MRI inflammation of SI joints or radiographic sacroiliitis who have high disease activity (ASDAS≥2.1) and failed ≥2 NSAIDs (Figure). BASDAI is no longer recommended to assess treatment start. Current practice is to start a TNFi or IL-17i as there is more accumulated evidence, particularly on safety, and experience with these drug classes. The continuation of a b/tsDMARD should be considered if an improvement of ASDAS≥1.1 has been achieved after ≥12 weeks. The new recommendation 10 addresses extra-musculoskeletal manifestations, with TNF monoclonal antibodies preferred for recurrent uveitis or inflammatory bowel disease, and IL-17i for significant psoriasis. In light of overdiagnosis and overtreatment, treatment failure should trigger re-evaluation of the diagnosis and consideration of the presence of comorbidities (#11 – new). If active axSpA is confirmed after failing a b/tsDMARD, switching to another b/tsDMARD is recommended (#12). Tapering, but not immediate discontinuation of a bDMARD, can be considered in patients in sustained remission (#13). The unchanged recommendations #14 and #15 deal with surgery and spinal fractures.

Conclusion: The 2022 ASAS-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.

ASAS-EULAR recommendations for the management of axial spondyloarthritis, 2022 update

ASAS-EULAR recommendations for the treatment of patients with axSpA with b/tsDMARDs

Disclosures: S. Ramiro, AbbVie/Abbott, Eli Lilly, Galapagos, Merck/MSD, Novartis, Pfizer, UCB, Sanofi; E. Nikiphorou, Pfizer, Celltrion, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Fresenius; A. Sepriano, UCB, Novartis; A. Ortolan, None; C. Webers, None; X. Baraliakos, AbbVie, Lilly, Galapagos, MSD, Novartis, Pfizer, UCB, Bristol-Myers Squibb, Janssen, Roche, Sandoz, Sanofi; R. Landewé, Abbott, Amgen, AstraZeneca, BMS, GSK, Novartis, Merck, Pfizer, Schering-Plough, UCB Pharma; F. Van den bosch, AbbVie, Lilly, Galapagos, Janssen, Merck, Novartis, Pfizer, UCB, Amgen, Bristol-Myers Squibb(BMS), Celgene; B. Boteva, None; A. Bremander, None; P. Carron, Biogen, AbbVie/Abbott, Eli Lilly, Fresenius Kabi, Galapagos, Merck/MSD, Pfizer, Sanofi, UCB; A. Ciurea, AbbVie, Novartis, Merck/MSD; f. van Gaalen, Stichting vrienden van Sole Mio, Stichting ASAS, Jacobus stichting, Novartis, UCB, MSD, AbbVie, Bristol Myers Squibb, Eli Lilly; P. Geher, AbbVie/Abbott; L. Gensler, Novartis, Pfizer Inc, UCB Pharma, AbbVie, Eli Lilly, Janssen, Gilead, Moonlake; J. Hermann, AbbVie/Abbott, Novartis, Janssen, Eli Lilly; M. de Hooge, None; M. Husakova, Novartis; U. Kiltz, AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, Pfizer, Biocad, Lilly, Grünenthal, Janssen, MSD, Roche, UCB; C. Lopez-Medina, None; P. Machado, AbbVie/Abbott, Eli Lilly, UCB, Novartis, Orphazyme, Galapagos; H. Marzo-Ortega, None; A. Molto, Abbvie, UCB, Novartis, Gilead, Pfizer, Lilly, Jannsen; V. Navarro-Compán, AbbVie, Eli Lilly, Janssen, Merck/MSD, Novartis, Pfizer, UCB Pharma; M. Nissen, AbbVie/Abbott, Pfizer, Amgen, Novartis, Janssen; F. Pimentel-Santos, AbbVie/Abbott, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Bial, Pharma Kern, Tecnimed, Biogen; D. Poddubnyy, AbbVie, Biocad, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, MSD, Moonlake, Novartis, Pfizer, Samsung-Bioepis, UCB; F. Proft, AbbVie/Abbott, Amgen, Bristol-Myers Squibb(BMS), Celgene, Eli Lilly, Janssen, Merck/MSD, Novartis, Pfizer, Roche, UCB; M. Rudwaleit, AbbVie, Bristol-Myers Squibb (BMS), Boehringer-Ingelheim, Chugai, Eli Lilly, Janssen, Novartis, Pfizer, UCB Pharma; M. Telkman, None; S. Zhao, UCB; N. Ziade, Pfizer, Roche, AbbVie/Abbott, Eli Lilly, Boehringer-Ingelheim, Janssen; D. van der Heijde, AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Novartis, Pfizer, UCB, Imaging Rheumatology bv, Lilly.

To cite this abstract in AMA style:

Ramiro S, Nikiphorou E, Sepriano A, Ortolan A, Webers C, Baraliakos X, Landewé R, Van den bosch F, Boteva B, Bremander A, Carron P, Ciurea A, van Gaalen f, Geher P, Gensler L, Hermann J, de Hooge M, Husakova M, Kiltz U, Lopez-Medina C, Machado P, Marzo-Ortega H, Molto A, Navarro-Compán V, Nissen M, Pimentel-Santos F, Poddubnyy D, Proft F, Rudwaleit M, Telkman M, Zhao S, Ziade N, van der Heijde D. ASAS-EULAR Recommendations for the Management of Axial Spondyloarthritis: 2022 Update [abstract]. Arthritis Rheumatol. 2022; 74 (suppl 9). https://acrabstracts.org/abstract/asas-eular-recommendations-for-the-management-of-axial-spondyloarthritis-2022-update/. Accessed .

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