Table 3. TLAR Expert Opinions for Axial Spondyloarthritis Treatment.

	Level of agreement LoA	Strength of recommendation
Basic Principles
1.  Ax-SpA is a potentially severe disease. A multidisciplinary approach in coordination of a rheumatologist or physical medicine and rehabilitation specialist is required for the management of musculoskeletal and extraarticular manifestations.	9.29±2.22
2.  The main aims of the treatment of patients with ax-SpA are to control the inflammation and symptoms, to prevent structural damage, to minimize comorbidities, to avoid adverse effects of the treatment, normalization and preservation of functionality and social participation, and maximization of the health-related quality of life.	9.89±0.31
3. Non-pharmacological and pharmacological treatment methods should be combined in the ideal treatment of patients with ax-SpA.	9.25±2.35
4. The treatment of ax-SpA should rely on the shared decision between patient and physician, and should aim the best treatment and care.	9.36±1.74
5. Ax-SpA has high personal, medical, and societal costs. All of them should be kept in mind in the management of the disease.	9.18±1.76
Recommendations
1.  The treatment of ax-SpA patients should be individualized considering current symptom and signs of the disease (axial, peripheral, extraarticular), comorbid situations, psychosocial factors, request and expectations of patients.	9.36±1.74	D
2.  The monitoring of ax-SpA should consist of clinical signs, laboratory tests, patient-reported outcome indices, and convenient imaging methods according to clinical signs, also considering the ASAS core set*. The frequency of disease monitoring should be adjusted for each patient depending on symptoms, disease severity, and treatment type*. The disease activity should be assessed according to clinical signs and acute phase reactants**. ASDAS is a preferred scale in ax-SpA, and should be used to determine treatment goals**.	9.21±1.47	*D
		**B
3.  Treatment goal should be remission or inactive disease. The treatment should be planned and conducted according to treatment target. Low/minimal disease activity may be an alternative treatment target in some cases.	9.39±1.74	D
4a.  Patient should be informed about his/her disease*. This education should include relevant issues concerning his/her medical condition and treatment**. Patient should be able to reach education in entire course of his/her disease**. Patient should be encouraged for smoking cessation programs**.	9.75±2.09	*B
		**D
4b.  Non-pharmacological treatment methods should be applied as soon as the diagnosis is established*. An individualized exercise program adjusted according to clinical condition and expectations should be structured and applied**. This program should be followed according to general principles and contraindications***.	9.64±0.62	*C
		**D
		***C
5.  Patients complaining of pain and stiffness should use lowest effective doses of NSAIDs as first-line medication. Continuous use of NSAIDs should be preferred in patients responding well, and becoming symptomatic on discontinuation of NSAIDs. The risk and benefits should be taken into consideration in use of NSAIDs.	9.07±1.82	A
6.  In case of persistent pain, when prior treatments are unsuccessful, contraindicated, and/or intolerated, paracetamol and opioid-like analgesics may be added to the treatment.	8.29±2.15	D
7.  Glucocorticoid injections may be performed for local inflammatory conditions of the musculoskeletal system*. Long-term systemic glucocorticoid use is not recommended for patients with axial involvement**.	8.64±2.24	*B
		**D
8.  Conventional synthetic DMARDs are not recommended for patients with pure axial involvement normally. Sulfasalazine may be considered for patients with peripheral arthritis.	8.71±1.83	A
9. Use of bDMARDs (the current practice is to start with a TNFi) should be considered for the patients with high disease activity despite standard treatments.	9.75±0.58	A
10. In case of failed TNFi treatment, switching to another TNFi* or a IL17i** should be thought.	9.61±0.68	*B
		**A
11. In patients with persistent remission, tapering bDMARDs may be thought.	9.32±1.31	B
12a. In the presence of refractory pain or functional impairment and radiographic structural damage; total hip arthroplasty should be thought independent of age.	9.46±0.88	C
12b. Spinal surgical interventions such as corrective osteotomy or stabilization in specialized centers may provide benefit in selected cases with severe, disabling spinal deformity.	8.61±1.39	C
13a. Risk factors regarding cardiovascular comorbidities should be overviewed in all ax-SpA patients.	9.07±1.56	C-D
13b. Patients with ax-SpA should be informed about increased fracture risk. They should be assessed in terms of osteoporosis.	9.50±0.79	C
13c. The spinal pain evolving abruptly and not considered to be related to inflammation should be investigated, appropriate evaluation including imaging should be performed. In case of acute vertebral fracture, consultation of a spinal surgeon and examination should assuredly be sought.	9.39±0.99	D