ACR Recommendations for Ankylosing Spondylitis: A Quiz

November 12, 2018

Take this 5-question quiz for a quick refresher on the ACR guidelines.

Take this 5-question quiz for a quick refresher on the ACR guidelines for ankylosing spondylitis.

References:

1. Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2016;68:282-298. doi: 10.1002/art.39298.

The American College of Rheumatology (ACR) guidelines for ankylosing spondylitis emphasize the strong evidence for treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor (TNF) inhibitors.¹ Scroll through the slides to test your knowledge of the guidelines with the following 5-question quiz.

Question 1. Which of the following NSAIDs is the preferred choice in the treatment of active ankylosing spondylitis?

ANSWER: The 2015 ACR guidelines strongly recommend NSAIDs for active ankylosing spondylitis. However, the ACR does not recommend any specific NSAID over any other. According to the guidelines, the choice of NSAID should be based on the patient’s history of NSAID use and risk factors for adverse events. The ACR conditionally recommends continual treatment with NSAIDs over on-demand treatment.

Question 2. True or false? Systemic glucocorticoids are recommended as first-line treatment in ankylosing spondylitis.

ANSWER: According to the 2015 guidelines, the ACR strongly recommends against systemic glucocorticoids in the treatment of active ankylosing spondylitis. However, in a limited number of circumstances, short-term glucocorticoid therapy with rapid tapering could be considered. These settings include polyarticular flares of peripheral arthritis, flares during pregnancy, and concomitant flares of inflammatory bowel disease.

Question 3. In stable ankylosing spondylitis treated with a TNF inhibitor and an NSAID, the ACR recommends:

ANSWER: In stable ankylosing spondylitis treated with NSAIDs and TNF inhibitors, the ACR conditionally recommends treating with TNF inhibitors alone rather than continuing with both medications. This recommendation is based on evidence suggesting a high risk of relapse following withdrawal of the TNF inhibitor. The ACR suggests a trial of NSAID withdrawal because the benefits of doing so may outweigh the harms of continuing dual therapy. Continued NSAID therapy may increase the risk of GI, renal, cardiac, and hematologic toxicity. In stable ankylosing spondylitis, the ACR conditionally recommends on-demand treatment with NSAIDs rather than continual therapy.

Question 4. In active ankylosing spondylitis that has not responded adequately to NSAIDs, the ACR recommends which of the following as preferred treatment?

ANSWER: According to the 2015 ACR guidelines, TNF inhibitor therapy is strongly recommended in patients with active ankylosing spondylitis that has not responded adequately to NSAIDs. However, the ACR does not recommend any particular TNF inhibitor over another, because of limited evidence comparing efficacy and toxicity of TNF inhibitors in this setting. The exception is patients with inflammatory bowel disease or frequently recurrent iritis, for whom the ACR recommends infliximab or adalimumab as preferred medications over etanercept.

Note: In January 2016, the FDA approved Cosentyx^® (secukinumab, Novartis) for treatment of adults with active ankylosing spondylitis and active psoriatic arthritis. The 2015 ACR guidelines are currently being updated to include this medication but have yet to be released.

Question 5. The ACR prefers which of the following for rehabilitation in active ankylosing spondylitis?

ANSWER: For rehabilitation of active ankylosing spondylitis, the ACR strongly recommends physical therapy, and conditionally recommends active supervised exercise over passive therapy such as massage, ultrasound, and heat. Because one of the goals of physical therapy is to train patients in independent exercise, the ACR stresses active interventions. In addition, the ACR conditionally recommends active land-based physical therapy over aquatic therapy, because of the absence of strong evidence favoring aquatic interventions.