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    Patent Pending

    Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis (beta)

    Based on guidelines from the American College of Rheumatology.

    Strength
    Strong recommendation
    Moderate recommendation
    Conditional recommendation
    Weak recommendation
    Evidence
    High quality evidence
    Moderate to high quality evidence
    Moderate quality evidence
    Low to moderate quality evidence
    Low quality evidence
    Very low to high quality evidence
    Very low to moderate quality evidence
    Very low to low quality evidence
    Very low quality evidence

    Treatment - Active / Stable AS

    Pharmacologic Treatment
    1. In adults with active AS, ACR strongly recommends treatment with NSAIDs over no treatment with NSAIDs.
    2. In adults with active AS, ACR conditionally recommends continuous treatment with NSAIDs over on-demand treatment with NSAIDs.
    3. In adults with active AS, ACR does not recommend any particular NSAID as the preferred choice.
    4. In adults with active AS despite treatment with NSAIDs, ACR conditionally recommends against treatment with SAARDs.
    5. In adults with active AS despite treatment with NSAIDs, ACR strongly recommends treatment with TNFi over no treatment with TNFi.
    6. In adults with active AS despite treatment with NSAIDs, ACR does not recommend any particular TNFi as the preferred choice, except for patients with concomitant inflammatory bowel disease or recurrent iritis.
    7. In adults with active AS despite treatment with NSAIDs and who have contraindications to TNFi, ACR conditionally recommends treatment with a SAARD over treatment with a non-TNFi biologic agent.
    8. In adults with active AS despite treatment with the first TNFi used, ACR conditionally recommends treatment with a different TNFi over adding a SAARD.
    9. In adults with active AS despite treatment with the first TNFi used, ACR conditionally recommends treatment with a different TNFi over treatment with a non-TNFi biologic agent.
    10. In adults with active AS, ACR strongly recommends against treatment with systemic glucocorticoids.
    11. In adults with AS and isolated active sacroiliitis despite treatment with NSAIDs, ACR conditionally recommends treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids.
    12. In adults with AS with stable axial disease and active enthesitis despite treatment with NSAIDs, ACR conditionally recommends using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. Peri-tendon injections of Achilles, patellar, and quadriceps tendons should be avoided.
    13. In adults with AS with stable axial disease and active peripheral arthritis despite treatment with NSAIDs, ACR conditionally recommends using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids.
    14. In adults with stable AS, ACR conditionally recommends on-demand treatment with NSAIDs over continuous treatment with NSAIDs.
    15. In adults with stable AS receiving treatment with TNFi and NSAIDs, ACR conditionally recommends continuing treatment with TNFi alone compared to continuing both treatments.
    16. In adults with stable AS receiving treatment with TNFi and SAARDs, ACR conditionally recommends continuing treatment with TNFi alone over continuing both treatments.
    Rehabilitation
    1. In adults with active AS, ACR strongly recommends treatment with physical therapy over no treatment with physical therapy.
    2. In adults with active AS, ACR conditionally recommends active physical therapy interventions (supervised exercise) over passive physical therapy interventions (massage, ultrasound, heat).
    3. In adults with active AS, ACR conditionally recommends land-based physical therapy interventions over aquatic therapy interventions.
    4. In adults with stable AS, ACR strongly recommends treatment with physical therapy over no treatment with physical therapy.
    5. In adults with active or stable AS, ACR conditionally recommends advising unsupervised back exercises.
    6. In adults with active or stable AS and spinal fusion or advanced spinal osteoporosis, ACR strongly recommends against treatment with spinal manipulation.
    Monitoring
    1. In adults with active or stable AS, ACR conditionally recommends the regular-interval use and monitoring of a validated AS disease activity measure.
    2. In adults with active or stable AS, ACR conditionally recommends regular-interval use and monitoring of the CRP concentrations or erythrocyte sedimentation rate (ESR) over usual care without regular CRP or ESR monitoring.

    Treatment - Specific Comorbidities

    Hip Arthritis
    1. In adults with AS and advanced hip arthritis, ACR strongly recommends treatment with total hip arthroplasty over no surgery.
    Severe Kyphosis
    1. In adults with AS and severe kyphosis, ACR conditionally recommends against elective spinal osteotomy.
    Acute Iritis
    1. In adults with AS and acute iritis, ACR strongly recommends treatment by an ophthalmologist to decrease the severity, duration, or complications of episodes.
    Recurrent Iritis
    1. In adults with AS and recurrent iritis, ACR conditionally recommends prescription over no prescription of topical glucocorticoids for prompt at-home use in the event of eye symptoms to decrease the severity or duration of iritis episodes.
    2. In adults with AS and recurrent iritis, ACR conditionally recommends treatment with infliximab or adalimumab over treatment with etanercept to decrease recurrences of iritis.
    Inflammatory Bowel Disease
    1. In adults with AS and inflammatory bowel disease, ACR does not recommend any particular NSAID as the preferred choice to decrease the risk of worsening of inflammatory bowel disease symptoms.
    2. In adults with AS and inflammatory bowel disease, ACR strongly recommends using treatment with TNFi monoclonal antibodies over treatment with etanercept.

    Preventive Care

    Education
    1. In adults with AS, ACR conditionally recommends participation in formal group or individual self-management education.
    2. In adults with AS, ACR conditionally recommends fall evaluation and counseling.
    Preventive Care
    1. In adults with AS, ACR conditionally recommends screening for osteopenia/osteoporosis with dual x-ray absorptiometry (DXA) scanning over no screening.
    2. In adults with AS and syndesmophytes or spinal fusion, ACR conditionally recommends screening for osteoporosis/osteopenia with DXA scanning of the spine as well as the hips, compared to DXA scanning solely of the hip or other non-spine sites.
    3. In adults with AS, ACR strongly recommends against screening for cardiac conduction defects with electrocardiograms.
    4. In adults with AS, ACR strongly recommends against screening for valvular heart disease with echocardiograms.

    Nonradiographic Axial SpA

    Pharmacologic Treatment
    1. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, ACR conditionally recommends treatment with TNFi over no treatment with TNFi.
    What do the icons mean?  
    Research PaperWard 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;68(2):282-98.