Axial Spondyloarthritis Management (ASAS-EULAR 2022)

Algorithm Steps

1. ▶

   Start

   Confirmed Axial Spondyloarthritis

   Diagnosis per ASAS criteria (radiographic or non-radiographic)

   1. ●

      Action

      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)
      1. ●

         Action

         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
         1. ●

            Action

            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
            1. ◆

               Decision

               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
               1. ●

                  Action

                  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
                  1. ✓

                     Outcome

                     axSpA Controlled

                     Remission or low disease activity achieved, maintenance therapy

               2. ●

                  Action

                  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)
                  1. ⚠

                     Warning

                     ⚠️ 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)
                     1. ◆

                        Decision

                        bDMARD Response at 12-16 Weeks?

                        Assess ASDAS or BASDAI

                        1. ●

                           Action

                           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
                           1. ●

                              Action

                              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
                              1. ⚠

                                 Warning

                                 Specialist Referral

                                 Refractory disease, complex EAMs, clinical trial

               3. ●

                  Action

                  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