New Treatment Guidelines for Ankylosing Spondylitis

The American College of Rheumatology has published new guidelines for the treatment of ankylosing spondylitis, emphasizing the strong evidence for treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor (TNF) blockers.

A committee of rheumatology experts evaluated the evidence for these and other treatments for both active and stable ankylosing spondylitis (AS); for ankylosing spondylitis plus comorbidities; and, for non-radiographic spondyloarthritis. They considered studies that examined health status, functional status, morbidities and adverse events, focusing on the clinical questions that physicians and patients wrestle with daily.

The resulting recommendations are qualified as "strongly in favor," "conditionally in favor," "conditionally against" and "strongly against." Strong recommendations should be accepted by most patients offered the treatment, while conditional recommendations require education and shared decision-making, the researchers wrote.

In an interview with Rheumatology Network, Michael Ward, MD, MPH, a researcher for the National Institutes of Health and the principle investigator on the project, said, “This covers medications, drug treatments, physical therapy and rehab, surgery, comorbid conditions, preventative care and disease monitoring." The new recommendations were published online simultaneously in the journals Arthritis Care and Research and Arthritis and Rheumatology on September 24.[[{"type":"media","view_mode":"media_crop","fid":"43769","attributes":{"alt":"©bleakstar/Shuttersstock.com","class":"media-image media-image-right","id":"media_crop_3222623101901","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4847","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":" ","typeof":"foaf:Image"}}]]

Ankylosing spondylitis can have significant effects on quality of life and productivity. One 2013 study, published in the journal Annals of the Rheumatic Diseases, found that 15.7 percent of anklylosing spondylitis patients recruited for a trial of certolizumab pegol reported being unable to work because of their disease, and 42 percent said they required frequent assistance from friends, family and caregivers in daily activities.

The new guideline committee found strong evidence for treatment of active ankylosing spondylitis with NSAIDs over no NSAIDs, but no evidence that any particular NSAID outperforms any other. This may be because NSAIDs are generally equally effective or because studies on the drugs haven't been designed to clarify that question, Ward said. 

In patients for whom NSAIDs aren't effective, TNF inhibitors are strongly recommended. There was no evidence to recommend one TNF inhibitor over another, except in patients with comorbid inflammatory bowel disease or recurrent iritis; for patients with those conditions, the panel preferred treatment with infliximab or adalimumab over etanercept.

Other key recommendations include a strong caution against treatment with  systemic glucocorticoids for active ankylosing spondylitis and a strong recommendation for physical therapy. Supervised exercise was conditionally recommended over passive physical therapy such as massage, and land-based physical therapy conditionally preferred over aquatic therapy.

Key ACR recommendations for the treatment of anklyosing spondylitis:

In addition, the new recommendations conditionally call for continuous treatment with NSAIDs over on-demand treatment with NSAIDs for active ankylosing spondylitis. Treatment with slow-acting anti-rheumatic drugs (SAARDs) are not recommended unless the patient has contraindications to TNF inhibitors, in which case SAARDs are conditionally preferred over a non-TNFi biologic agent.

For adults with stable ankylosing spondylitis, the ACR now conditionally recommends continuing treatment with TNF inhibitors alone instead of both NSAIDs and TNF inhibitors. Similarly, for adults with stable AS being treated with TNF inhibitors and SAARDs, the group conditionally recommends continuing treatment with TNF inhibitors alone. Physical therapy is strongly recommended for patients with stable ankylosing spondylitis. Fall evaluation and group or individual patient education are conditionally recommended for patients with both stable and active ankylosing spondylitis.

Though the authors also considered evidence for the treatment of non-radiographic axial spondyloarthritis, this relatively new condition has yet to be fully researched. Five controlled trials of adalimumab, certolizumab, etanercept and infliximab provided moderate-quality evidence for the treatment with TNF inhibitors over a placebo. Patients should be engaged in the decision to try these medications, Ward and his colleagues wrote. The remainder of the guidelines on non-radiographic axial spondyloarthritis were based on research on ankylosing spondylitis and thus were identical to the ankylosing spondylitis recommendations.

The guidelines were developed with the Spondylitis Association of America and the Spondyloarthritis Research and Treatment Network. Developers used a method called Grading of Recommendations Assessment, Development and Evaluation (GRADE) to evaluate the evidence at hand.

The recommendations should clarify the treatment options for anklyosing spondylitis and nonradiographic axial spondyloarthritis, but there were "large gaps" in research into both disorders, Ward said. In particular, little is known about the best sequence of second- and third-line treatments if the preferred options fail.

"Included in that is when to taper or withdraw medications," Ward said. More work on the benefits of physical therapy and types of physical therapy are is needed, he said. And the current recommendations were developed based on research on adults only.

"There is a whole set of questions related to children with AS that still need to be addressed," Ward said.

References:

Ward, M. M., Deodhar, A., Akl, E. A., Lui, A., Ermann, J., Gensler, L. S., Smith, J. A., Borenstein, D., Hiratzka, J., Weiss, P. F., Inman, R. D., Majithia, V., Haroon, N., Maksymowych, W. P., Joyce, J., Clark, B. M., Colbert, R. A., Figgie, M. P., Hallegua, D. S., Prete, P. E., Rosenbaum, J. T., Stebulis, J. A., van den Bosch, F., Yu, D. T. Y., Miller, A. S., Reveille, J. D. and Caplan, L. (2015), 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 Care Res. doi: 10.1002/acr.22708

Van der Heijde, D., Purcaru, O., Kavanaugh, A. High economic burden of axial spondyloarthritis related to paid work and household productivity at baseline in the rapid-axspa study: differences and similarities between ankylosing spondylitis and non-radiographic axial spondyloarthritis. Ann Rheum Dis 2013;72:A523-A524 doi:10.1136/annrheumdis-2013-eular.1566.