To update and integrate the recommendations for ankylosing spondylitis and the recommendations
for the use of tumour necrosis factor inhibitors (TNFi) in axial spondyloarthritis
(axSpA) into one set applicable to the full spectrum of patients with axSpA. Following
the latest version of the European League Against Rheumatism (EULAR) Standardised
Operating Procedures, two systematic literature reviews first collected the evidence
regarding all treatment options (pharmacological and non-pharmacological) that were
published since 2009. After a discussion of the results in the steering group and
presentation to the task force, overarching principles and recommendations were formulated,
and consensus was obtained by informal voting. A total of 5 overarching principles
and 13 recommendations were agreed on. The first three recommendations deal with personalised
medicine including treatment target and monitoring. Recommendation 4 covers non-pharmacological
management. Recommendation 5 describes the central role of non-steroidal anti-inflammatory
drugs (NSAIDs) as first-choice drug treatment. Recommendations 6-8 define the rather
modest role of analgesics, and disprove glucocorticoids and conventional synthetic
disease-modifying antirheumatic drugs (DMARDs) for axSpA patents with predominant
axial involvement. Recommendation 9 refers to biological DMARDs (bDMARDs) including
TNFi and IL-17 inhibitors (IL-17i) for patients with high disease activity despite
the use (or intolerance/contraindication) of at least two NSAIDs. In addition, they
should either have an elevated C reactive protein and/or definite inflammation on
MRI and/or radiographic evidence of sacroiliitis. Current practice is to start with
a TNFi. Switching to another TNFi or an IL-17i is recommended in case TNFi fails (recommendation
10). Tapering, but not stopping a bDMARD, can be considered in patients in sustained
remission (recommendation 11). The final two recommendations (12, 13) deal with surgery
and spinal fractures. The 2016 Assessment of SpondyloArthritis international Society-EULAR
recommendations provide up-to-date guidance on the management of patients with axSpA.
