0542: ASAS-EULAR Recommendations for the Management of Axial Spondyloarthritis: 2022 Update

Sofia Ramiro¹, Elena Nikiphorou², Alexandre Sepriano³, Augusta Ortolan⁴, Casper Webers⁵, Xenofon Baraliakos⁶, Robert Landewé⁷, Filip Van den bosch⁸, Boryana Boteva⁹, Ann Bremander¹⁰, Philippe Carron¹¹, Adrian Ciurea¹², floris van Gaalen¹, Pal Geher¹³, Lianne Gensler¹⁴, Josef Hermann¹⁵, Manouk de Hooge¹⁶, Marketa Husakova¹⁷, Uta Kiltz¹⁸, Clementina Lopez-Medina¹⁹, Pedro Machado²⁰, Helena Marzo-Ortega²¹, Anna Molto²², Victoria Navarro-Compán²³, Michael Nissen²⁴, Fernando Pimentel-Santos²⁵, Denis Poddubnyy²⁶, Fabian Proft²⁶, Martin Rudwaleit²⁷, Mark Telkman⁹, Sizheng Zhao²⁸, Nelly Ziade²⁹ and Désirée van der Heijde³⁰, ¹Leiden University Medical Center, Leiden, Netherlands, ²Leiden University Medical Center & King's College London, London, United Kingdom, ³Leiden University Medical Centre, Portela Loures, Portugal, ⁴University of Padova/Leiden University Medical Center, Padova, Italy, ⁵Maastricht University Medical Centre, Maastricht, Netherlands, ⁶Rheumazentrum Ruhrgebiet Herne, Herne, Germany, ⁷Amsterdam University Medical Center, Meerssen, Netherlands, ⁸Department of Internal Medicine and Paediatrics, Ghent University and VIB Centre for Inflammation Research, Ghent, Belgium, ⁹Patients with Arthritis and Rheumatism (PARE) working group, EULAR, Zürich, Switzerland, ¹⁰Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark, ¹¹Ghent University Hospital, Ghent, Belgium, ¹²University Hospital Zurich, Zürich, Switzerland, ¹³Semmelweis University, Budapest, Hungary, ¹⁴Department of Medicine, Division of Rheumatology, University of California San Francisco, San Francisco, CA, ¹⁵Medical University of Graz, Graz, Austria, ¹⁶Ghent University Hospital, Luxembourg, Luxembourg, ¹⁷Department of Rheumatology, First Faculty of Medicine, Charles University and Rheumatology Institute, Prague, Prague, Czech Republic, ¹⁸Rheumazentrum Ruhrgebiet, Herne, Germany, ¹⁹Reina Sofia University Hospital, Rheumatology Department, Jaén, Spain, ²⁰University College London, London, United Kingdom, ²¹Leeds Teaching Hospitals Trust and University of Leeds, Leeds, United Kingdom, ²²Rheumatology Department, Hôpital Cochin,Assistance Publique- Hôpitaux de Paris, Paris, France, ²³Department of Rheumatology, La Paz University Hospital, IdiPaz, Madrid, Spain, ²⁴Hopitaux Universitaires de Genève, Geneva, Switzerland, ²⁵NOVA Medical School; Universidade NOVA e Lisboa, Lisboa, Portugal, ²⁶Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité – Universitätsmedizin Berlin, Berlin, Germany, ²⁷University of Bielefeld, Klinikum Bielefeld, Bielefeld; Germany Klinikum Bielefeld and Charité Berlin, Germany, and Gent University, Gent, Belgium, ²⁸University of Manchester, Liverpool, United Kingdom, ²⁹Saint-Joseph University, Beirut, Lebanon, ³⁰Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands, Leiden, Netherlands

Background/Purpose: Since the last update of the ASAS-EULAR recommendations for the management of axial spondyloarthritis (axSpA) in 2016, substantial new evidence has become available on the management of axSpA. Our aim was to update the ASAS-EULAR recommendations for the management of axSpA.

Methods: Following the EULAR Standardised Operating Procedures, two systematic literature reviews were conducted on non-pharmacological and pharmacological treatment of axSpA. During a task force meeting the evidence was presented, discussed and overarching principles and recommendations were updated, followed by voting.

Results: A total of 5 overarching principles (unchanged compared to the previous version of the recommendations) and 15 recommendations were formulated (Table). All recommendations included in the previous version were kept: eight unchanged (#2,3,6,7,8,13,14,15); three with minor edits, mostly on nomenclature (#1,4,5) and two with relevant updates (#9,12), while two newly formulated recommendations (#10,11) were added. The first 5 recommendations focus on personalised medicine, including 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 DMARDs for pure axial involvement. Recommendation 9 describes the indication for biological DMARDs (bDMARDs i.e. TNFi, IL-17i) and this was expanded to targeted synthetic DMARDs (tsDMARDs i.e. JAKi). b/tsDMARDs are indicated for patients with elevated CRP, MRI inflammation of SI joints or radiographic sacroiliitis who have high disease activity (ASDAS≥2.1) and failed ≥2 NSAIDs (Figure). BASDAI is no longer recommended to assess treatment start. Current practice is to start a TNFi or IL-17i as there is more accumulated evidence, particularly on safety, and experience with these drug classes. The continuation of a b/tsDMARD should be considered if an improvement of ASDAS≥1.1 has been achieved after ≥12 weeks. The new recommendation 10 addresses extra-musculoskeletal manifestations, with TNF monoclonal antibodies preferred for recurrent uveitis or inflammatory bowel disease, and IL-17i for significant psoriasis. In light of overdiagnosis and overtreatment, treatment failure should trigger re-evaluation of the diagnosis and consideration of the presence of comorbidities (#11 - new). If active axSpA is confirmed after failing a b/tsDMARD, switching to another b/tsDMARD is recommended (#12). Tapering, but not immediate discontinuation of a bDMARD, can be considered in patients in sustained remission (#13). The unchanged recommendations #14 and #15 deal with surgery and spinal fractures.

Conclusion: The 2022 ASAS-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.
ASAS-EULAR recommendations for the management of axial spondyloarthritis, 2022 update

ASAS-EULAR recommendations for the treatment of patients with axSpA with b/tsDMARDs
Disclosures: S. Ramiro, AbbVie/Abbott, Eli Lilly, Galapagos, Merck/MSD, Novartis, Pfizer, UCB, Sanofi; E. Nikiphorou, Pfizer, Celltrion, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Fresenius; A. Sepriano, UCB, Novartis; A. Ortolan, None; C. Webers, None; X. Baraliakos, AbbVie, Lilly, Galapagos, MSD, Novartis, Pfizer, UCB, Bristol-Myers Squibb, Janssen, Roche, Sandoz, Sanofi; R. Landewé, Abbott, Amgen, AstraZeneca, BMS, GSK, Novartis, Merck, Pfizer, Schering-Plough, UCB Pharma; F. Van den bosch, AbbVie, Lilly, Galapagos, Janssen, Merck, Novartis, Pfizer, UCB, Amgen, Bristol-Myers Squibb(BMS), Celgene; B. Boteva, None; A. Bremander, None; P. Carron, Biogen, AbbVie/Abbott, Eli Lilly, Fresenius Kabi, Galapagos, Merck/MSD, Pfizer, Sanofi, UCB; A. Ciurea, AbbVie, Novartis, Merck/MSD; f. van Gaalen, Stichting vrienden van Sole Mio, Stichting ASAS, Jacobus stichting, Novartis, UCB, MSD, AbbVie, Bristol Myers Squibb, Eli Lilly; P. Geher, AbbVie/Abbott; L. Gensler, Novartis, Pfizer Inc, UCB Pharma, AbbVie, Eli Lilly, Janssen, Gilead, Moonlake; J. Hermann, AbbVie/Abbott, Novartis, Janssen, Eli Lilly; M. de Hooge, None; M. Husakova, Novartis; U. Kiltz, AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, Pfizer, Biocad, Lilly, Grünenthal, Janssen, MSD, Roche, UCB; C. Lopez-Medina, None; P. Machado, AbbVie/Abbott, Eli Lilly, UCB, Novartis, Orphazyme, Galapagos; H. Marzo-Ortega, None; A. Molto, Abbvie, UCB, Novartis, Gilead, Pfizer, Lilly, Jannsen; V. Navarro-Compán, AbbVie, Eli Lilly, Janssen, Merck/MSD, Novartis, Pfizer, UCB Pharma; M. Nissen, AbbVie/Abbott, Pfizer, Amgen, Novartis, Janssen; F. Pimentel-Santos, AbbVie/Abbott, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Bial, Pharma Kern, Tecnimed, Biogen; D. Poddubnyy, AbbVie, Biocad, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, MSD, Moonlake, Novartis, Pfizer, Samsung-Bioepis, UCB; F. Proft, AbbVie/Abbott, Amgen, Bristol-Myers Squibb(BMS), Celgene, Eli Lilly, Janssen, Merck/MSD, Novartis, Pfizer, Roche, UCB; M. Rudwaleit, AbbVie, Bristol-Myers Squibb (BMS), Boehringer-Ingelheim, Chugai, Eli Lilly, Janssen, Novartis, Pfizer, UCB Pharma; M. Telkman, None; S. Zhao, UCB; N. Ziade, Pfizer, Roche, AbbVie/Abbott, Eli Lilly, Boehringer-Ingelheim, Janssen; D. van der Heijde, AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Novartis, Pfizer, UCB, Imaging Rheumatology bv, Lilly.