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2022 ASAS-EULAR Guidelines for Axial Spondyloarthritis

Oct 24, 2022 8:00 am

Assessment of SpondyloArthritis international Society (ASAS) and EULAR have published their 2022 update and recommendations for the management of axial spondyloarthritis (axSpA).

These recommendations are based on review of the literature by a task force that included 33 participants, from 16 countries across Europe and North America, including rheumatologists, epidemiologists, EULAR representatives from the health professionals committee, People with Arthritis/Rheumatism across Europe, EMerging EUlar NETwork and Young-ASAS. These recommendations address the management of axSpA in all it's clinical forms - axial disease, peripheral arthritis, enthesitis, dactylitis, comorbidities and extramusculoskeletal manifestations (acute anterior uveitis, inflammatory bowel disease and psoriasis).

The final manuscript includes 5 overarching principles and 15 recommendations - 8 unchanged from the previous recommendations; 3 minor edits on nomenclature; two with relevant updates (#9, 12); two newly formulated (#10, 11). The first five recommendations focus on 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 disease-modifying antirheumatic drugs (DMARDs) for pure axial involvement. Recommendation 9 describes the indication of biological DMARDs (bDMARDs, that is, tumour necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i)) and targeted synthetic DMARDs (tsDMARDs, ie, Janus kinase inhibitors) for patients who have Ankylosing Spondylitis Disease Activity Score ≥2.1 and failed ≥2 NSAIDs and also have either elevated C reactive protein, MRI inflammation of sacroiliac joints or radiographic sacroiliitis. Current practice is to start a TNFi or IL-17i. 

Overarching Principals

  • axSpA is a potentially severe disease with diverse manifestations, requiring multidisciplinary management coordinated by the rheumatologist
  • The primary goal of treating the patient with axSpA is to maximise health-related quality of life through control of symptoms and inflammation, prevention of progressive structural damage, and preservation/normalisation of function and social participation.
  • The optimal management of patients with axSpA requires a combination of non-pharmacological and pharmacological treatments
  • Treatment of axSpA should aim at the best care and must be based on a shared decision between the patient and rheumatologist.
  • axSpA incurs high individual, medical and societal costs, all of which should be considered in its management 


  1. The treatment of patients with axSpA should be individualised according to the current signs and symptoms of the disease, comorbidities and psychosocial factors

  2. Disease monitoring of patients with axSpA should include patient-reported outcomes, clinical findings, laboratory tests and imaging; frequency should be decided on an individual basis 

  3. Treatment should be guided according to a predefined treatment target

  4. Patients should be educated about axSpA and encouraged to exercise on a regular basis and stop smoking; physiotherapy should be considered

  5. Patients suffering from pain and stiffness should use an NSAID as first-line drug treatment up to the maximum dose. For patients who respond well to NSAIDs, continuous use is preferred if needed to control symptoms.

  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

  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

  8. Patients with purely axial disease should normally not be treated with csDMARDs; sulfasalazine may be considered in patients with peripheral arthritis

  9. TNFi, IL-17i† or JAKi should be considered in patients with persistently high disease activity despite conventional treatments; current practice is to start a TNFi or IL-17i 

  10. If there is a history of recurrent uveitis or active IBD, preference should be given to a monoclonal antibody against TNF; In patients with significant psoriasis, an IL-17i may be preferred.

  11. Absence of response to treatment should prompt re-evaluation of the diagnosis and consideration of the presence of comorbidities

  12. Following a first b/tsDMARD failure, switching to another bDMARD (TNFi or IL-17i) or a JAKi should be considered

  13. If a patient is in sustained remission, tapering of a bDMARD can be considered

  14. 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

  15. 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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The author has no conflicts of interest to disclose related to this subject