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

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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
Article numberA78
Pages (from-to)19-34
JournalAnnals of the rheumatic diseases
Issue number1
Early online date21 Oct 2022
Publication statusPublished - 3 Jan 2023


  • Biological Therapy
  • Spondyloarthritis
  • Therapeutics


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