EULAR and ASAS have adopted new treatment management guidelines for axial spondyloarthritis that emphasize treat to target, tapering and for the first time, cost considerations. EULAR and ASAS have adopted new treatment management guidelines for axial spondyloarthritis that emphasize treat to target, tapering and for the first time, cost considerations.
The recommendations apply to all patients with axial spondyloarthritis (axSpA) irrespective of radiographic sacroiliitis, and they include the new class of biologic disease modifying anti-rheumatic drugs, the interleukin-17 inhibitors.
For the first time, cost considerations were a factor in considering recommendations. “The task force considers this an important aspect, given the extreme drug costs for individual patients and society, and feels a responsibility to help minimizing total health care expenditures for patients with axSpA,” the authors wrote. “In case of similar efficacy and safety, the cheapest treatment option can be chosen. Tapering of a bDMARD is also recommended as an option, but again under the condition of maximizing health-related quality of life.”
Unlike the 2015 American College of Rheumatology (ACR) and SpondyloArthritis Research and Treatment Network (SPARTAN) recommendations for ankylosing spondylitis and non-radiographic axSpA which are based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, the ASAS-EULAR recommendations are based on the Oxford LoE to assess the evidence of the literature. The differences in the EU and U.S. recommendations primarily center on areas where strong evidence is lacking (eg, corrective osteotomy, injections with glucocorticoids).
The ACR-SPARTAN recommendations are grouped by stage and disease presentation, while the ASAS-EULAR recommendations are condensed and integrated. There are 38 ACR-SPARTAN recommendations as compared to 13 ASAS-EULAR recommendations. The ASAS-EULAR recommendations consider treatment according to a target, the conditions for starting bDMARDs; tapering bDMARDs, IL-17i use; taking cost into account; and, treating axSpA as one continuum of the disease.
The recommendations are based on five overarching principles the authors consider, “so generic and implicit in nature that they serve as a basis for the state-of-the-art management of patients with Axial Spondyloarthritis. As such, they reflect the state of practice rather than the state of science.”
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Desiree van der Jeijde, Sofia Ramiro, Robert Landewe, et al. “2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis” Annals of the Rheumatic Diseases. 2017;0:1–14. DOI:10.1136/annrheumdis-2016-210770