Objectives To update the Assessment of SpondyloArthritis international Society (ASAS)-EULAR
recommendations for the management of axial spondyloarthritis (axSpA). Methods Following
the EULAR Standardised Operating Procedures, two systematic literature reviews were
conducted on non-pharmacological and pharmacological treatment of axSpA. In a task
force meeting, the evidence was presented, discussed, and overarching principles and
recommendations were updated, followed by voting. Results Five overarching principles
and 15 recommendations with a focus on personalised medicine were agreed: eight remained
unchanged from the previous recommendations; three with 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. Recommendation 10 addresses extramusculoskeletal manifestations with TNF
monoclonal antibodies preferred for recurrent uveitis or inflammatory bowel disease,
and IL-17i for significant psoriasis. Treatment failure should prompt re-evaluation
of the diagnosis and consideration of the presence of comorbidities (#11). If active
axSpA is confirmed, switching to another b/tsDMARD is recommended (#12). Tapering,
rather than immediate discontinuation of a bDMARD, can be considered in patients in
sustained remission (#13). The last recommendations (#14, 15) deal with surgery and
spinal fractures. Conclusions The 2022 ASAS-EULAR recommendations provide up-to-date
guidance on the management of patients with axSpA.
