2014 Update on the CRA/SPARCC Treatment Recommendations for the Management of SpA.
| Recommendation | LOE | SOR | EO |
|---|---|---|---|
| General management principles | |||
| 1. Management recommendations for SpA will be organized under the categories of axSpA (including nr-axSpA) and peripheral SpA. | IV | D | 4.9 |
| 2. The goal of treatment is remission. When remission is not possible, the goal is minimal disease activity and control of symptoms, prevention of damage, and improvement in quality of life. Therapy should be adjusted until these goals are reached. | IV (SpA) II (PsA) | D (SpA) B (PsA) | 4.9 |
| 3. Optimal management of SpA includes a combination of nonpharmacological and pharmacological treatments, as well as patient education. | I | A | 5.0 |
| 4. Patient preferences, including risk-benefit balances, must be incorporated into regulatory decision-making and prescribing of arthritis medications. | IV | D | 5.0 |
| 5. It is appropriate to consider pharmacoeconomic data in formulating decisions on management strategies. The particular aim is to identify subgroups of patients with the highest burden of disease for whom the additional benefits merit the additional costs. | IV | D | 4.5 |
| 6. Postmarketing evaluation of new therapies for SpA should be implemented to ensure appropriate access and utilization of these agents, and to ensure their safety in an unselected population with longer periods of observation. | IV | D | 5.0 |
| Ethical considerations | |||
| 7. A Formulary Committee has a duty to represent the public’s interests in promoting the greatest health benefits possible (ethical principle of Beneficence) as fairly as possible within society’s limited shared resources (Justice) through an open and transparent process and in accordance with the best available evidence (Accountability). | IV | D | 4.7 |
| 8. Economic evaluations should be comprehensive with a clear analysis of the direct and indirect costs of suboptimal treatment. Ethically, suboptimal treatment is always questionable (principle of Nonmaleficence). | IV | D | 4.5 |
| 9. Fairness across all patient groups and illness categories is mandatory, and is enshrined in the Canada Health Act. Ad hoc decisions that favor some groups but not others are not ethically acceptable. | IV | D | 4.9 |
| 10. Resource limitations may require that qualifications be placed on access to some extremely expensive therapies. Physicians must be enabled to practice the highest standard of evidence-based medicine for the benefit of their patients, and thus even extremely expensive therapies that are clinically effective must not be excluded on principle. Formulary committees should be encouraged to work in conjunction with clinical specialists to develop guidelines for access that promote safe and effective interventions at lower cost where possible, but that allow clinicians and patients to access necessary therapeutics when other options are not medically appropriate. | IV | D | 4.9 |
| 11. In a Canadian context, the delivery of healthcare is a provincial rather than federal responsibility. However, the principles of universality, transferability, and comprehensiveness of the Canada Health Act, and the underlying ethical principle of Justice, indicate that treatments approved in 1 province should generally be available to patients in all provinces. | IV | D | 4.9 |
| Target groups for treatment recommendations | |||
12. These management recommendations are intended for:
| IV | D | 4.9 |
| Wait time recommendations | |||
| 13. Patients with chronic back pain with an age of onset prior to 45 should be screened for the presence of SpA and assessed by a rheumatologist within 3 mos of referral. Patients at risk of peripheral SpA should be assessed by a rheumatologist within 6 weeks of referral. | IV | D | 4.1 |
| 14. MRI frequently plays an important role in the diagnosis of SpA. When a rheumatologist orders an MRI to diagnose SpA, the whole spine and pelvis should be imaged. MRI imaging should occur within 6 weeks of being ordered by the rheumatologist. | IV (timing) II (whole spine) | D(timing) B (whole spine) | 4.5 |
| Disease monitoring | |||
| 15. Specific disease monitoring of patients with SpA in clinical practice should ideally include: | |||
| a. Patient history | IV | D | 4.8 |
| b. Relevant clinical exam (axial or peripheral). For axSpA, spinal mobility should be assessed. All patients should have an assessment of tender joints, swollen joints, and enthesitis. | IV | D | 4.8 |
| c. Baseline screening for hepatitis B virus and other chronic infection, liver disease, renal disease, and malignancy. | IV | D | 4.8 |
| d. Assessment for signs and symptoms of extraarticular manifestations of SpA (in particular, inflammatory bowel disease, uveitis, and psoriasis). | IV | D | 4.8 |
| e. Assessment for signs and symptoms of comorbid conditions associated with inflammatory arthritis (i.e., CV disease, hypertension, hyperlipidemia, DM, and osteoporosis). | IV | D | 4.8 |
| f. BASDAI questionnaire. | IV | D | 4.8 |
| g. Assessment of function. | IV | D | 4.8 |
| h. Patient assessment of global well-being. | IV | D | 4.8 |
| i. CRP/ESR. | II | B | 4.8 |
| j. Drug toxicity (including infection and malignancy) and adherence. | IV | D | 4.8 |
| k. Appropriate imaging, including plain radiographs and/or MRI of the axial skeleton and involved peripheral joints. | II | B | 4.8 |
| l. Quality of life assessment. | IV | D | 4.8 |
| m. Participation in activities and work disability. | IV | D | 4.9 |
| n. Frequency of disease monitoring will depend on disease severity, treatment type, and patient preference. | IV | D | 5.0 |
| o. Monitoring and management of extraarticular manifestations of SpA (i.e., IBD, uveitis, psoriasis) should be in collaboration with respective specialists as needed. | IV | D | 5.0 |
| p. Monitoring and management of comorbid conditions associated with inflammatory arthritis (i.e., CV disease, hypertension, hyperlipidemia, DM, osteoporosis) should be in collaboration with primary care physicians and respective specialists as needed. | IV | D | 4.9 |
CRA: Canadian Rheumatology Association; SPARCC: Spondyloarthritis Research Consortium of Canada; SpA: spondyloarthritis; LOE: level of evidence; SOR: strength of recommendation; EO: expert opinion; axSpA: axial SpA; PsA: psoriatic arthritis; nr-axSpA: nonradiographic axSpA; MRI: magnetic resonance imaging; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; IBD: inflammatory bowel disease; CV: cardiovascular; DM: diabetes mellitus.