Table 3.
Recommendations for the treatment of adults with nonradiographic axial spondyloarthritis (nonradiographic axial SpA). Recommendations with asterisks are from 2015 and were not reviewed in this update.
| Recommendations for adults with active nonradiographic axial SpA |
Level of evidence | PICO |
|---|---|---|
| 52. We strongly recommend treatment with NSAIDs over no treatment with NSAIDs.* | Very low | 34 |
| 53. We conditionally recommend continuous treatment with NSAIDs over on‐demand treatment with NSAIDs. | Very low | 33 |
| 54. We do not recommend any particular NSAID as the preferred choice.* | Very low | 35 |
| 55. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with sulfasalazine, methotrexate, or tofacitinib over no treatment with these medications. | Very low | 39 |
| 56. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we strongly recommend treatment with TNFi over no treatment with TNFi. | High | 38 |
| 57. We do not recommend any particular TNFi as the preferred choice. | Very low | 37 |
| 58. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi over treatment with tofacitinib. | Very low | 73 |
| 59. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with secukinumab or ixekizumab over no treatment with secukinumab or ixekizumab. | Very low | 71 |
| 60. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi over treatment with secukinumab or ixekizumab. | Very low | 72 |
| 61. In adults with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with secukinumab or ixekizumab over treatment with tofacitinib. | Very low | 74 |
| 62. In adults with active nonradiographic axial SpA despite treatment with NSAIDs and who have contraindications to TNFi, we conditionally recommend treatment with secukinumab or ixekizumab over treatment with sulfasalazine, methotrexate, or tofacitinib. | Very low | 40 |
| 63. In adults with active nonradiographic axial SpA and primary nonresponse to the first TNFi used, we conditionally recommend switching to secukinumab or ixekizumab over switching to a different TNFi. | Very low | 42 |
| 64. In adults with active nonradiographic axial SpA and secondary nonresponse to the first TNFi used, we conditionally recommend switching to a different TNFi over switching to a non-TNFi biologic. | Very low | 42 |
| 65. In adults with active nonradiographic axial SpA despite treatment with the first TNFi used, we strongly recommend against switching to the biosimilar of the first TNFi. | Very low | 75 |
| 66. In adults with active nonradiographic axial SpA despite treatment with the first TNFi used, we conditionally recommend against the addition of sulfasalazine or methotrexate in favor of treatment with a different biologic. | Very low | 41 |
| 67. We strongly recommend against treatment with systemic glucocorticoids.* | Very low | 36 |
| 68. In adults with isolated active sacroiliitis despite treatment with NSAIDs, we conditionally recommend treatment with local glucocorticoids over no treatment with local glucocorticoids.* | Very low | 45 |
| 69. In adults with active enthesitis despite treatment with NSAIDs, we conditionally recommend using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids. Peri‐tendon injections of Achilles, patellar, and quadriceps tendons should be avoided.* | Very low | 46 |
| 70. In adults with active peripheral arthritis despite treatment with NSAIDs, we conditionally recommend using treatment with locally administered parenteral glucocorticoids over no treatment with local glucocorticoids.* | Very low | 47 |
| 71. We strongly recommend treatment with physical therapy over no treatment with physical therapy.* | Low | 22 |
| 72. We conditionally recommend active physical therapy interventions (supervised exercise) over passive physical therapy interventions (massage, ultrasound, heat).* | Very low | 23 |
| 73. We conditionally recommend land‐based physical therapy interventions over aquatic therapy interventions.* | Very low | 24 |
| Recommendations for adults with stable nonradiographic axial SpA | ||
| 74. We conditionally recommend on-demand treatment with NSAIDs over continuous treatment with NSAIDs. | Very low | 33 |
| 75. In adults receiving treatment with TNFi and NSAIDs, we conditionally recommend continuing treatment with TNFi alone compared to continuing both medications. | Very low | 43 |
| 76. In adults receiving treatment with TNFi and a conventional synthetic antirheumatic drug, we conditionally recommend continuing treatment with TNFi alone over continuing treatment with both medications. | Very low | 44 |
| 77. In adults receiving treatment with a biologic, we conditionally recommend against discontinuation of the biologic. | Low | 79 |
| 78. In adults receiving treatment with a biologic, we conditionally recommend against tapering of the biologic dose as a standard approach. | Very low | 78 |
| 79. In adults receiving treatment with an originator TNFi, we strongly recommend continuation of treatment with the originator TNFi over mandated switching to its biosimilar. | Very low | 76 |
| Recommendations for adults with active or stable nonradiographic axial SpA | ||
| 80. In adults receiving treatment with TNFi, we conditionally recommend against co-treatment with low-dose methotrexate. | Low | 77 |
| Disease activity assessment and Imaging | ||
| 81. We conditionally recommend the regular‐interval use and monitoring of a validated AS disease activity measure.* | Very low | 56 |
| 82. We conditionally recommend regular‐interval use and monitoring of the CRP concentrations or erythrocyte sedimentation rate (ESR) over usual care without regular CRP or ESR monitoring.* | Very low | 57 |
| 83. In adults with active nonradiographic axial SpA, we conditionally recommend against using a treat-to-target strategy using a target of ASDAS < 1.3 (or 2.1) over a treatment strategy based on physician assessment. | Very low | 80 |
| 84. In adults with nonradiographic axial SpA of unclear activity while on a biologic, we conditionally recommend obtaining a spinal or pelvis MRI to assess activity. | Very low | 81 |
| 85. In adults with stable nonradiographic axial SpA, we conditionally recommend against obtaining a spinal or pelvis MRI to confirm inactivity. | Very low | 82 |
| 86. In adults with active or stable nonradiographic axial SpA on any treatment, we conditionally recommend against obtaining repeat spine radiographs at a scheduled interval (e.g., every 2 years) as a standard approach. | Very low | 83 |