ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update

Sofia Ramiro*, Elena Nikiphorou, Alexandre Sepriano, Augusta Ortolan, Casper Webers, Xenofon Baraliakos, Robert B M Landewé, Filip E Van den Bosch, Boryana Boteva, Ann Bremander, Philippe Carron, Adrian Ciurea, Floris A van Gaalen, Pál Géher, Lianne Gensler, Josef Hermann, Manouk de Hooge, Marketa Husakova, Uta Kiltz, Clementina López-MedinaPedro M Machado, Helena Marzo-Ortega, Anna Molto, Victoria Navarro-Compán, Michael J Nissen, Fernando M Pimentel-Santos, Denis Poddubnyy, Fabian Proft, Martin Rudwaleit, Mark Telkman, Sizheng Steven Zhao, Nelly Ziade, Désirée van der Heijde

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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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.

Original languageEnglish
Pages (from-to)19-34
Number of pages16
JournalAnnals of the Rheumatic Diseases
Issue number1
Early online date21 Oct 2022
Publication statusPublished - Jan 2023


  • Biological Therapy
  • Spondyloarthritis
  • Therapeutics

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