Updated CRA/SPARCC Recommendations for Axial Spondyloarthritis Save

KEY TAKEAWAYS

• Compared to the 2024 CRA/SPARCC recommendations, this update reassesses the use of IL-17i inhibitors in SpA. (All 56 other recommendations remain unchanged)
• IL-17i treatment option for active axSpA (after NSAID failure) - bimekizumab is now recommended alongside secukinumab and ixekizumab (in both r-axSpA and nr-axSpA)
• All IL-17 inhibitors are equally effective with no IL-17i superiority over another for musculoskeletal outcomes. Selection may be influenced by driven by extra-musculoskeletal manifestations (EMMs - IBD, uveitis, psoriasis), safety or patient preference
• IL-17i remain contraindicated in active IBD
• Monoclonal TNFi are still preferred for recurrent or active uveitis

In 2024, the Canadian Rheumatology Association (CMA) and the Spondyloarthritis Research Consortium of Canada (SPARCC) published a comprehensive set of 56 treatment recommendations for the management of axial spondyloarthritis (axSpA). The original CRA/SPARCC recommendations endorsed IL-17i (secukinumab, ixekizumab) and TNF inhibitors (TNFi) as equivalent second-line options for adults with active axSpA who fail an adequate NSAID trial. JAK inhibitors (upadacitinib, tofacitinib) were reserved for patients with prior bDMARD failure, reflecting Health Canada approval conditions at the time.

This first update is focused on the reassessment of IL-17i recommendations. The original positioning addressed IL-17i vs. TNFi vs. JAKi. How will the availability of bimekizumab's phase 3 data (BE MOBILE 1 & 2) and 2-year durability results be integrated into these recommendations?

IL-17i Class Recommendations

Bimekizumab is now formally included alongside secukinumab and ixekizumab as a recommended IL-17i option for adults with active axSpA failing NSAIDs. The recommended dose for both r-axSpA and nr-axSpA is 160 mg subcutaneously every 4 weeks. The panel acknowledged the higher cost of bimekizumab relative to established IL-17i agents but concluded that it is acceptable, feasible, and may offer another  effective alternative for patients with inadequate responses to prior IL-17i agents.

The update reinforces that no IL-17i is broadly superior to another for musculoskeletal outcomes. Agent selection should be individualized based on xtra-musculoskeletal manifestations (EMMs), especially with: 

• Concurrent psoriasis: IL-17i (particularly bimekizumab and higher-dose secukinumab) offer superior skin efficacy and may be preferred with significant cutaneous psoriasis.
• Infection risk: Bimekizumab carries an increased incidence of oropharyngeal candidiasis relative to selective IL-17A inhibitors, reflecting dual IL-17A/F blockade.
• Prior IL-17i exposure: Bimekizumab may be considered after failure of an IL-17A inhibitor, mainly for its mechanistic difference (additional IL-17F blockade), rather than RCT showing efficacy of bimekizumab after anti-IL-17A inhibitor failure.
• IL-17i are not recommended as first-line in active inflammatory bowel disease (IBD).
• Monoclonal TNFi remain preferred for uveitis; observational data suggest IL-17A inhibitors (secukinumab, ixekizumab) may be less effective than monoclonal TNFi for uveitis control, though bimekizumab may have a more favorable uveitis profile based on post-hoc analyses.

When primary or secondary failure occurs with one bDMARD class, the panel continues to recommend switching to a different mechanism of action (e.g., TNFi to IL-17i, or vice versa) rather than cycling within class, except where specific clinical circumstances — such as partial response with EMM considerations — justify an intra-class switch.