Confirmed Axial Spondyloarthritis
Diagnosis per ASAS criteria (radiographic or non-radiographic)
All Pathways
RheumatologyManagement
Axial Spondyloarthritis Management (ASAS-EULAR 2022)
Axial Spondyloarthritis Management (ASAS-EULAR 2022): Confirmed Axial Spondyloarthritis → Overarching Principles → Non-Pharmacological Treatment → First...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Overarching Principles
Foundation of axSpA management
- Shared decision-making with patient
- Treatment goal: remission or low disease activity
- Multi-disciplinary care (rheum, PT, ophthalmology, gastro)
- Assessment: ASDAS (preferred), BASDAI, CRP, MRI as needed
- Consider extra-articular manifestations (uveitis, IBD, psoriasis)
03Action Non-Pharmacological Treatment
Fundamental for all patients
- Regular exercise and physical therapy (Strong)
- Structured exercise program (group or individual)
- Smoking cessation (impacts disease and cardiovascular risk)
- Patient education and self-management
- Occupational therapy if needed
04Action First-Line: NSAID Trial
If no contraindications (Strong)
- Full-dose NSAID (e.g., naproxen 500mg BID, celecoxib 200mg BID)
- Try ≥2 different NSAIDs (at least 2-4 weeks each)
- Continuous use if symptom control requires it
- Monitor GI, renal, and cardiovascular risk
- csDMARDs (MTX, SSZ) NOT effective for axial disease
05Decision Adequate Response to NSAIDs?
Assess disease activity after 2-4 weeks per NSAID
- ASDAS: inactive (<1.3), low (1.3-2.1), high (2.1-3.5), very high (>3.5)
- Goal: ASDAS <2.1 or improvement ≥1.1
- Consider positive prognostic factors: CRP+, MRI inflammation+, smoking, male
06Action Maintenance Therapy
Sustained remission/low disease activity
- Continue effective therapy long-term
- May consider dose reduction in sustained remission
- Do NOT stop bDMARD abruptly (high relapse risk)
- Continue exercise and non-pharmacological measures
- Regular monitoring for EAMs and drug safety
07Outcome axSpA Controlled
Remission or low disease activity achieved, maintenance therapy
08Action bDMARD Therapy
After NSAID failure (Strong)
- TNF inhibitor OR IL-17 inhibitor first-line bDMARD
- TNFi: adalimumab, certolizumab, etanercept, golimumab, infliximab
- IL-17i: secukinumab, ixekizumab
- No clear preference between TNFi and IL-17i for pure axSpA
- If IBD present: prefer TNFi (not IL-17i)
09Warning ⚠️ Extra-Articular Manifestations
Influence drug selection
- Uveitis: TNFi monoclonals (adalimumab, infliximab) preferred
- IBD: TNFi (adalimumab, infliximab); AVOID IL-17i
- Psoriasis: IL-17i or TNFi both effective
- Peripheral arthritis: may respond to csDMARDs (SSZ, MTX)
10Decision bDMARD Response at 12-16 Weeks?
Assess ASDAS or BASDAI
- Path rejoins step 06Shared downstream outcome
11Action Switch bDMARD or Add JAKi
If first bDMARD fails
- Switch to different mechanism: TNFi ↔ IL-17i
- May try second drug within same class
- JAKi (tofacitinib, upadacitinib) as option after bDMARD failure
- Consider extra-articular manifestation in drug selection
12Action JAK Inhibitor Option
After bDMARD failure or if bDMARD unsuitable
- Tofacitinib 5mg BID
- Upadacitinib 15mg daily (FDA approved for AS)
- Assess CV, VTE, malignancy risk (similar considerations as RA)
- Consider patient preference and risk factors
- Path rejoins step 07Shared downstream outcome
13Warning Specialist Referral
Refractory disease, complex EAMs, clinical trial
14Action Peripheral Arthritis Component
If present alongside axial disease
- NSAIDs first-line as for axial
- Local glucocorticoid injections for active joints/entheses
- Sulfasalazine may help peripheral arthritis
- Methotrexate: limited evidence but used in practice
- bDMARDs if peripheral symptoms persist
- Path rejoins step 08Shared downstream outcome
Guideline Source
ASAS-EULAR Recommendations for the Management of Axial Spondyloarthritis: 2022 Update
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Peripheral spondyloarthritis may have different treatment approach
- Extra-articular manifestations require multidisciplinary input
- Does not address pediatric/JIA-related SpA
- Drug availability varies by region
- Cardiovascular screening not detailed
Contraindicated Populations
pediatric
Applicable Regions
EUUSAU
AU: ARA endorses ASAS-EULAR recommendations
EU: ASAS-EULAR 2022 is primary guidance
US: ACR/SAA/SPARTAN 2019 also available
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Axial Spondyloarthritis Management (ASAS-EULAR 2022)?
The Axial Spondyloarthritis Management (ASAS-EULAR 2022) is a management clinical algorithm for Rheumatology. It provides a structured decision tree to guide clinical decision-making, based on ASAS-EULAR Recommendations for the Management of Axial Spondyloarthritis: 2022 Update.
What guideline is the Axial Spondyloarthritis Management (ASAS-EULAR 2022) based on?
This algorithm is based on ASAS-EULAR Recommendations for the Management of Axial Spondyloarthritis: 2022 Update (DOI: 10.1136/ard-2022-223296).
What are the limitations of the Axial Spondyloarthritis Management (ASAS-EULAR 2022)?
Known limitations include: Peripheral spondyloarthritis may have different treatment approach; Extra-articular manifestations require multidisciplinary input; Does not address pediatric/JIA-related SpA; Drug availability varies by region; Cardiovascular screening not detailed. Individual patient factors may require deviation from these recommendations.
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