2014 Update on the CRA/SPARCC Specific Treatment Recommendations for the Management of SpA.
| Recommendation | LOE | SOR | EO |
|---|---|---|---|
| Nonpharmacological | |||
| 1. Nonpharmacological treatment of SpA should include patient education and regular exercise, preferably at centers of expertise or with experienced physiotherapists. Individual and group physical therapy should be considered. Patient associations and self-help groups may be useful. | I (physio) II (exercise) I (education) IV (self-help) | A (physio) B (exercise) A (education) D (self-help) | 5.0 |
| 2. Smoking contributes to radiographic progression in axSpA, and smoking cessation should be recommended. | II | B | 5.0 |
| NSAID and analgesics | |||
| 3. NSAID are recommended as first-line drug treatment for symptomatic patients with axSpA. A sufficient trial of therapy is defined as at least 2 NSAID, each administered over a minimum 2-week period at the maximum tolerated dosage, unless contraindicated. | I | A | 4.9 |
| 4. The decision to use NSAID should be made after considering the patient’s cardiovascular risk factors. NSAID with the best cardiovascular safety profile should be preferred. | I | A | 4.9 |
| 5. When there is no therapeutic advantage, selective COX-2 inhibitor therapy should be used in patients at increased risk for GI adverse events. In patients at risk who respond best to a traditional NSAID, a gastroprotective agent can be used. | I | A | 4.7 |
| 6. Patients on longterm, regular NSAID therapy should be regularly monitored for changes in GI, cardiovascular, and renal status. | I | B | 4.7 |
| 7. If NSAID are insufficient or contraindicated, alternative pain control strategies (i.e., acetaminophen, opioids) should be considered. It should be noted that non-NSAID analgesics do not control inflammation. | IV | D | 4.9 |
| Corticosteroids | |||
| 8. Corticosteroid injections at local sites of inflammation (i.e., SI joints, peripheral joints, and entheses) may be considered. | I (SI joints) II (PsA joint) IV (all other sites) | A (SI joints) B (PsA joint) D (all other sites) | 4.7 |
| 9. Short courses of systemic corticosteroids may be considered for specific manifestations. The sustained use of systemic steroids is not recommended or supported. | I (AS) IV (other SpA) | A (AS) D (other SpA) | 4.7 |
| DMARD | |||
| 10. There is no evidence for the efficacy of DMARD, including SSZ and MTX, for the treatment of axSpA. | I | A | 4.8 |
| 11. SSZ, MTX, and leflunomide may be considered in patients with peripheral SpA, but have only minimal to moderate evidence of efficacy. Dosing and monitoring of these drugs should be tailored to the individual patient and follow usual standard of care. | I | A | 4.9 |
| 12. Combination therapy with DMARD should be considered in peripheral SpA, particularly in patients with poor prognostic features, moderate–high disease activity and in patients with recent-onset disease. Combination therapy should also be considered in patients with inadequate response to monotherapy. | IV | D | 4.4 |
| Antibiotics | |||
| 13. A trial of rifampin plus either doxycycline or azithromycin may be tried for 6 mos in cases of proven post-Chlamydia chronic reactive arthritis. There is no evidence of efficacy for antibiotics in axSpA. | IV | D | 4.5 |
| TNFi | |||
| 14. TNFi should be given only under supervision by a rheumatologist to patients with persistently high disease activity, despite other therapy. Routine laboratory screening (complete blood count, liver and renal function) as well as screening for Hepatitis B and C (and HIV in high risk patients) should be performed prior to initiation. Screening for latent TB infection should be performed prior to initiation. Baseline ANA may be considered. CRA recommendations for prevention of TB should be followed. Seasonal vaccination for influenza is recommended for patients before or during treatment with TNFi. Hepatitis B vaccine should be considered in high-risk groups in patients determined to be nonimmune to HBV. H. zoster vaccine should be considered in patients aged 60 yrs or older. | IV | D | 4.9 |
| 15. There is no evidence to support the obligatory use of DMARD before, or concomitant with, TNFi in patients with axSpA. | I | A | 4.8 |
16. For patients with predominantly axSpA, TNFi should be offered to those with persistent symptoms after a trial of NSAID therapy as defined above and evidence of active disease as defined by at least 2 of the following:
| I (TNFi efficacy) IV (active disease definition) | A (TNFi efficacy) IV (active disease definition) | 4.2 |
| 17. For patients with predominantly peripheral SpA, TNF inhibitors should be offered to those with persistent inflammation despite a trial of NSAID as above and 1 DMARD. | I (TNFi efficacy) IV (post NSAID and DMARD) | A (TNFi efficacy) D (post NSAID and DMARD) | 4.9 |
| 18. For patients with refractory enthesitis or dactylitis, TNFi should be offered to those with persistent inflammation. | I (enthesitis) II (dactylitis) | A (enthesitis) B (dactylitis) | 4.5 |
| 19. Several TNFi are available for the treatment of SpA, including infliximab, etanercept, adalimumab, golimumab, and certolizumab. The choice of TNFi should be determined by consultation between the physician and patient. Dosing and monitoring of these drugs should be tailored to the individual patient and follow usual standard of care. | I | B | 5.0 |
| 20. Maintenance on TNFi should be based on attainment of clinical response 16 weeks after initiating treatment. In axSpA, a clinical response is defined as either an absolute reduction of the BASDAI by 2 (0–10 scale) or a relative reduction of 50%. In peripheral SpA, a clinical response is defined as a reduction in active joint count by 30%. | IV | D | 4.7 |
| 21. The choice of TNFi should incorporate the presence or absence of extraarticular manifestations. When possible, the chosen TNFi should treat both SpA and the particular extrarticular manifestations effectively. | I | A | 4.9 |
| 22. Combination of MTX and TNFi does not influence clinical efficacy, though in peripheral SpA it may be associated with prolonged drug response. | II | B | 4.5 |
| 23. Nonresponders to TNFi may benefit from switching to another TNFi. | II | B | 4.9 |
| Other biologic agents | |||
| 24. Rituximab may be considered for the treatment of axSpA for patients in whom TNFi are contraindicated. | II | B | 4.2 |
| 25. Ustekinumab may be considered for the treatment of patients with SpA with concomitant moderate to severe cutaneous psoriasis. | I | A | 4.8 |
| 26. There is currently no evidence for the use of other biologic agents in SpA, including ABA, TCZ, and anakinra. | II (ABA) I (TCZ) II (anakinra) | B (ABA) A (TCZ) B (anakinra) | 4.9 |
| Surgery | |||
| 27. Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age. | II (axial) IV (peripheral) | B (axial) D (peripheral) | 5.0 |
| 28. Spinal surgery, for example, corrective osteotomy and stabilization procedures, may be of value in selected patients, ideally at surgical centers with experience in AS spinal disease. | III | C | 4.8 |
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; NSAID: nonsteroidal antiinflammatory drugs; COX-2: cyclooxygenase-2; GI: gastrointestinal; SI: sacroiliac; PsA: psoriatic arthritis; AS: ankylosing spondylitis; DMARD: disease-modifying antirheumatic drugs; SSZ: sulfasalazine; MTX: methotrexate; TNFi: tumor necrosis factor inhibitors; HIV: human immunodeficiency virus; TB: tuberculosis; ANA: antinuclear antibody; HBV: hepatitis B virus; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; MRI: magnetic resonance imaging; ABA: abatacept; TCZ: tocilizumab.