National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland.
Oregon Health & Science University, Portland.
Arthritis Rheumatol. 2019 Oct;71(10):1599-1613. doi: 10.1002/art.41042. Epub 2019 Aug 22.
To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).
We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel.
Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended.
These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
更新治疗强直性脊柱炎（AS）和非放射学中轴型脊柱关节炎（SpA）患者的循证推荐意见。
我们对 2015 年指南中涉及药物治疗的 20 个临床问题和 26 个新的药物治疗、靶向治疗策略以及影像学应用问题进行了更新系统文献回顾。新问题涉及使用司库奇尤单抗、依奇珠单抗、托法替布、肿瘤坏死因子抑制剂（TNFi）生物类似药和生物制剂的减量/停药等。我们使用推荐分级的评估、制定与评价（GRADE）方法评估证据质量并制定推荐意见，需要投票小组成员至少 70%的一致同意。
AS 和非放射学中轴型 SpA 的推荐意见相似。TNFi 被推荐用于首选生物制剂，优于司库奇尤单抗或依奇珠单抗。在对首种 TNFi 无应答的患者中，推荐使用司库奇尤单抗或依奇珠单抗，而不是第二种 TNFi。TNFi、司库奇尤单抗和依奇珠单抗优于托法替布。不建议 TNFi 联合低剂量甲氨蝶呤，也不建议在病情稳定的患者中采用严格的靶向治疗策略或停止或减少生物制剂的使用。当 TNFi 禁忌时，仅推荐柳氮磺胺吡啶用于持续性外周关节炎。对于疾病活动度不明确的患者，脊柱或骨盆磁共振成像有助于评估。不建议常规监测连续脊柱 X 线片的放射学变化。
这些推荐意见为 AS 和非放射学中轴型 SpA 的管理中新型药物和轴向骨骼影像学的应用提供了更新的指导。
