Abhijeet Danve, MD, FACP, FACR, prepared useful Practice Aids pertaining to axial spondyloarthritis for this CME activity titled “Overcoming Challenges in the Diagnosis and Management of Axial Spondyloarthritis: New Insights and Implications for Clinical Practice.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/2A6Xi8d. CME credit will be available until August 27, 2021.

1. Access the activity, “Overcoming Challenges in the Diagnosis and
Management of Axial Spondyloarthritis: New Insights and Implications
for Clinical Practice,” at PeerView.com/WXC40
What Is Axial Spondyloarthritis?
PRACTICE AID
Axial Spondyloarthritis (axSpA)
• A painful chronic inflammatory disease that primarily affects the spine and sacroiliac joints
(SIJs)1
• Leading symptom: inflammatory back pain that improves with exercise but not with rest1
• Disease onset: usually before age of 45 years3,4
• Prevalence: 0.2%-1.4% of adults have axSpA, which is similar to RA3,5,6; equally prevalent
in both men and women4,7
Often MRI shows
evidence of
inflammation on SIJs
and spine2
AS is most
prevalent in men
(65%)9,10
No definitive SIJ
structural damage
on x-ray2
nr-axSpA is most
prevalent in women
(66%)9,10
10%-12% of patients with nr-axSpA
progress to AS in 2 years9,11
Definitive SIJ
structural damage
on x-ray2
~60%-70% of patients
with AS develop
bony growths that
lead to vertebra
fusion1,8
Nonradiographic axSpA
(nr-axSpA)
The presence or absence of structural
damage to SIJs on x-ray differentiates
nr-axSpA from AS2
Radiographic axSpA
(ankylosing spondylitis [AS])
SIJs

2. Access the activity, “Overcoming Challenges in the Diagnosis and
Management of Axial Spondyloarthritis: New Insights and Implications
for Clinical Practice,” at PeerView.com/WXC40
What Is Axial Spondyloarthritis?
PRACTICE AID
RA: rheumatoid arthritis.
1. Sieper J, van der Heijde D. Arthritis Rheum. 2013;65:543-551. 2. Deodhar A et al. Arthritis Rheumatol. 2016;68:1669-1676. 3. Reveille J et al. Arthritis Care Res. 2012;64:905-910. 4. Rudwaleit M et al. Ann
Rheum Dis. 2009;68:777-783. 5. Hamilton L et al. BMC Musculoskelet Disord. 2015;21:392. 6. Spector T. Rheum Dis Clin North Am. 1990;16:513-537. 7. Mease P, Khan M. Axial Spondyloarthritis. 1st ed.
St. Louis, MO: Elsevier; 2019. 8. Sieper J et al. Nat Rev Dis Prim. 2015;9:15013. 9. Baraliakos X, Braun J. RMD Open. 2015;1:e000053. 10. Boonen A et al. Semin Arthritis Rheum. 2015;44:556-562.
11. Wallman J et al. Arthritis Res Ther. 2015;17:378. 12. de Winter J et al. Arthritis Res Ther. 2016;18:196. 13. Strand V, Singh J. Mayo Clin Proc. 2017;92:555-564.
Inflammatory back pain
Severe stiffness
and reduced mobility
Fatigue and
difficulty sleeping
Decreased QOL
Impaired social
participation
Impaired work and
home productivity
• Uveitis: eye inflammation
• Enthesitis: inflammation
of the points of insertion
of tendons and ligaments
into bone
• Peripheral arthritis
• Psoriasis: skin disease
• IBD: chronic inflammation
of the digestive tract
• Dactylitis: inflammation
of the fingers or toes
Patients with nr-axSpA and AS
share common clinical features 2,8,11-13
and experience a significant
and similar disease burden2

3. Access the activity, “Overcoming Challenges in the Diagnosis and
Management of Axial Spondyloarthritis: New Insights and Implications
for Clinical Practice,” at PeerView.com/WXC40
Diagnostic Algorithm for
Axial Spondyloarthritis (axSpA)1
PRACTICE AID
ESR: erythrocyte sedimentation rate; HLA-B27: human leukocyte antigen B27; IBP: inflammatory back pain.
1. Taurog JD et al. N Engl J Med. 2016;374:2563-2574.
Low back pain present for >3 months
and age of onset <45 years
Definite radiographic sacroiliitis
Ankylosing
spondylitis
axSpA
axSpA axSpA
Consider
other
diagnosis
axSpA
Consider other
diagnosis
Presence of other spondyloarthritis features:
IBP, heel pain (enthesitis), dactylitis, uveitis,
positive family history for axSpA, IBD, alternating buttock pain,
psoriasis, asymmetrical arthritis, positive response
to NSAIDs, elevated ESR or C-reactive protein level
4 spondyloarthritis
features
2-3 spondyloarthritis
features
0-1 spondyloarthritis
features
HLA-B27HLA-B27
Compelling
clinical picture
HLA-B27
Compelling
clinical picture
Present Absent
Yes No Positive Negative Positive Negative
Positive Negative Yes No
Positive Negative
MRI

4. ASAS-Endorsed Recommendation for PCPs on Early
Referral of Patients With Suspected axSpA1
a
Any set of criteria, preferably ASAS definition of inflammatory back pain. b
Only if imaging is available, not recommended as routine screening parameter. c
According to the definition applied in the classification criteria for axSpA.
d
C-reactive protein serum concentration or erythrocyte sedimentation rate above upper normal limit after exclusion of other causes for elevation.
ASAS: Assessment of Spondyloarthritis International Society; axSpA: axial spondyloarthritis; HLA-B27: human leukocyte antigen B27.
1. Poddubnyy D et al. Ann Rheum Dis. 2015;74:1483-1487.
PRACTICE AID
Access the activity, “Overcoming Challenges in the Diagnosis and Management
of Axial Spondyloarthritis: New Insights and Implications for Clinical Practice,” at PeerView.com/WXC40
• Inflammatory back paina
• HLA-B27 positivity
• Sacroiliitis on imaging, if available (x-ray or MRI)b
• Peripheral manifestations (arthritis, enthesitis, dactylitis)c
• Extra-articular manifestations (psoriasis, IBD, uveitis)c
• Positive family history for spondyloarthritisc
• Good response to NSAIDsc
• Elevated acute phase reactantsd
Patients with chronic lower back pain lasting for 3 months or more
with an onset before aged 45 years should be referred to a rheumatologist
if at least one of the following parameters is present

5. Treatment Recommendations for Patients
With Ankylosing Spondylitis1
PRACTICE AID
Access the activity, “Overcoming Challenges in the Diagnosis and Management
of Axial Spondyloarthritis: New Insights and Implications for Clinical Practice,” at PeerView.com/WXC40
Treatment Recommendations for Active Ankylosing Spondylitis
Determine additional
disease manifestations
First-Line Therapy
PERIPHERAL PREDOMINANT
ARTHRITIS DESPITE NSAIDS
Local GCs (if ≤2 joints)
SSZ (SSZ over MTX)
Against LEF, APR, THL,
and PAM
ISOLATED SACROILIITIS
OR ENTHESITIS
NSAIDS
ISOLATED SACROILIITIS OR
ENTHESITIS DESPITE NSAIDS
Local GC
Avoid Achilles, patellar,
and quadriceps entheses
GC injections
General Adjunctive Management
• Unsupervised back exercises, formal group or individual self-management education,
fall evaluation/counseling
• Monitor using validated AS disease activity measures, and CRP or ESR regularly
• Adjunctive management is intended to occur at all stages
• Against using treat-to-target strategy with ASDAS <1.3 or 2.1 over strategy-based
on provider assessment; against obtaining repeat spine radiographs at a
scheduled interval
Determine
AS activity
See second-line therapy options
if patient does not respond to NSAIDs
ACTIVE AS
(AXIAL DISEASE)
NSAIDs
• Continuous
• No preferred NSAID
Physical therapy
• Active over passive
• Land-based over aquatic
Against systemic GCs
Strongly recommend
Conditionally recommend
Conditionally recommend against
Strongly recommend against
Legend for Treatment
Recommendations

6. Treatment Recommendations for Patients
With Ankylosing Spondylitis1
PRACTICE AID
Access the activity, “Overcoming Challenges in the Diagnosis and Management
of Axial Spondyloarthritis: New Insights and Implications for Clinical Practice,” at PeerView.com/WXC40
Second-Line
Therapy
AS AND RECURRENT
UVEITIS
OR AS + IBD
TNFi monoclonal
antibodies over
other biologics
AS WITH UNCLEAR ACTIVITY
WHILE ON BIOLOGIC
Spinal or pelvis MRI
Third-Line
Therapy
ACTIVE AS DESPITE TNFi
(2° NONRESPONDER)
Alternative TNFi
Against biosimilar
of first TNFi
Against non-TNFi
/non-SEC/IXE
or adding SSZ, MTX
Treatment Recommendations for Active Ankylosing Spondylitis
ACTIVE AS
DESPITE NSAIDS
TNF inhibitors (TNFis)
Over TOF, SEC/IXE
No preferred TNFi,
except for in patients
with AS + IBD or uveitis
ACTIVE AS DESPITE NSAIDS
(1° NONRESPONDER)
SEC/IXE (over TOF)
TOF
Against biosimilar
of first TNFi
Against non-TNFi /non-SEC
/IXE or adding SSZ, MTX
ACTIVE AS ON TNFi
Against cotreatment
with low-dose MTX

7. Treatment Recommendations for Patients
With Ankylosing Spondylitis1
APR: apremilast; AS: ankylosing spondylitis; ASDAS: Ankylosing Spondylitis Disease Activity Score; axSpA: axial spondyloarthritis; CRP: C-reactive protein level; csARD: conventional synthetic antirheumatic drugs; ESR: erythrocyte sedimentation rate; GC glucocorticoid;
IXE: ixekizumab; LEF: leflunomide; MTX: methotrexate; PAM: pamidronate; PICO: population, intervention, comparison, and outcomes; SEC: secukiniumab; SSZ: sulfasalazine; THL: thalidomide; TOF: tofacitinib.
1. Ward MM et al. Arthritis Rheumatol. 2019;71:1599-1613.
PRACTICE AID
Access the activity, “Overcoming Challenges in the Diagnosis and Management
of Axial Spondyloarthritis: New Insights and Implications for Clinical Practice,” at PeerView.com/WXC40
Treatment Recommendations for Stable Ankylosing Spondylitis
SEVERE KYPHOSIS
Avoid spinal osteotomy
SPINAL FUSION
OR ADVANCED OSTEOPOROSIS
Avoid spinal manipulation
ADVANCED HIP ARTHRITIS
Total hip arthroplasty
Determine AS activity
STABLE AS (AXIAL DISEASE)
NSAIDs
• On-demand
Physical therapy
STABLE AS ON BIOLOGIC
Against discontinuation
of biologic
Against biologic tapering
as a standard approach
STABLE AS ON TNFi + NSAID
Continue TNFi alone,
stop NSAID
STABLE AS ON TNFi
+ ORAL SMALL MOLECULE
Continue TNFi alone,
stop csARD
STABLE AS ON TNFi
If on originator TNFi,
do not switch to biosimilar TNFi
as a standard approach
Against cotreatment
with low-dose MTX
Determine additional
disease manifestations