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Axial spondyloarthritis

What's new

The British Society for Rheumatology (BSR) has released an updated guideline for the management of axial spondyloarthritis (axSpA), focusing on biological and targeted therapies. Biologic therapy with TNF, IL-17, or JAK inhibitors is recommended for patients with active axSpA who have not responded to conventional pharmacological and nonpharmacological treatment. IL-17 and monoclonal TNF inhibitors are preferred in patients with extensive psoriasis (>10% BSA) or severe localized psoriasis at high-impact sites. TNF and JAK inhibitors are preferred in the presence of inflammatory bowel disease, and monoclonal TNF inhibitors are preferred in patients with moderate-to-severe or recurrent uveitis. Response to targeted therapy should be assessed 3-4 months after initiation and every 6-12 months thereafter. Validated tools for assessing disease activity and treatment response include ASDAS, BASDAI, and spinal pain scores. Tapering of targeted therapies may be considered after achieving sustained remission, but full withdrawal is not recommended. .

Background

Overview

Definition
axSpA is a chronic inflammatory rheumatic disease primarily affecting the spine and sacroiliac joints. It includes both non-radiographic axSpA and radiographic axSpA, the latter also referred to as ankylosing spondylitis.
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Pathophysiology
Ankylosing spondylitis is strongly associated with the HLA-B27 genotype, although most persons with this genotype do not develop the disease. The etiology of joint inflammation in patients with ankylosing spondylitis involves the interaction of genetic predisposition and environmental factors with alterations in immune cell function, and cytokine regulation.
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Epidemiology
In the US, the annual incidence and prevalence of ankylosing spondylitis are 3.1 cases per 100,000 person-years and 197 persons per 100,000 population, respectively.
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Disease course
Clinical manifestations of ankylosing spondylitis include arthritis, dactylitis, ankylosis, osteoporosis of the spine and peripheral bones, uveitis, and IBD.
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Prognosis and risk of recurrence
Patients with ankylosing spondylitis have an increased risk of mortality, with an estimated standardized mortality ratio of 1.61. CVD is the most frequent cause of death (40%), followed by malignant (27%) and infectious (23%) diseases.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of axial spondyloarthritis are prepared by our editorial team based on guidelines from the British Society for Rheumatology (BSR 2025), the American College of Rheumatology (ACR 2023), the Assessment of SpondyloArthritis international Society (ASAS/EULAR 2023), the European League Against Rheumatism (EULAR 2023), the American College of Radiology (ACR 2021,2017), and the ...
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Classification and risk stratification

Severity assessment: as per BSR 2025 guidelines, determine active disease in the context of a verified diagnosis and inflammatory disease activity, supported by validated indices such as the axSpA Disease Activity Score, Bath Ankylosing Spondylitis Disease Activity Index, and spinal pain.
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Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
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When to use
How would you describe the overall level of fatigue/tiredness you have experienced?
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How would you describe the overall level of AS neck, back, or hip pain you have had?
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How would you describe the overall level of pain/swelling in joints other than neck, back, or hips you have had?
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How would you describe the overall level of discomfort you have had from any areas tender to touch or pressure?
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How would you describe the overall level of discomfort you have had from the time you wake up?
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How long does your morning stiffness last from the time you wake up?
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Calculation
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Diagnostic investigations

Diagnostic imaging: as per ACR 2021 guidelines, obtain radiography of sacroiliac joints or sacroiliac joints and spine area of interest as the initial imaging of suspected axSpA.
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  • Screening for osteoporosis

  • Screening for heart diseases

  • Screening for chronic infections

Medical management

General principles: as per BSR 2025 guidelines, aim to achieve predefined targets agreed upon with patients with axSpA by using individualized therapy adjustments that consider comorbidities and inflammatory disease activity.
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  • Management of active disease (NSAIDs)

  • Management of active disease (DMARDs)

  • Management of active disease (biologic agents)

  • Management of active disease (corticosteroids)

  • Management of stable disease

  • Management of pain

  • Management of uveitis

Nonpharmacologic interventions

Smoking cessation: as per ASAS/EULAR 2023 guidelines, advise smoking cessation in patients with ankylosing spondylitis.
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  • Physical therapy

  • Spinal manipulation

Therapeutic procedures

Local corticosteroid injections: as per ASAS/EULAR 2023 guidelines, consider administering corticosteroid injections directed to the local site of musculoskeletal inflammation.
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Surgical interventions

Spinal osteotomy: as per ASAS/EULAR 2023 guidelines, consider performing spinal corrective osteotomy in patients with severe disabling deformity in specialized centers.
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  • Total hip replacement

Specific circumstances

Patients with IBD
As per BSR 2025 guidelines:
Offer monoclonal TNF inhibitors or JAK inhibitors in the presence of active IBD. Do not use IL-17 inhibitors.
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Recognize that a history of inactive IBD is not an absolute contraindication to IL-17 inhibitors or etanercept.
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Patient education

General counseling: as per ASAS/EULAR 2023 guidelines, educate patients with axSpA about their condition.
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Preventative measures

Routine immunizations: as per ACR 2023 guidelines, consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in ≥ 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications.
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  • Prophylaxis for P. jirovecii pneumonia

Follow-up and surveillance

Monitoring of disease activity: as per ASAS/EULAR 2023 guidelines, assess patient-reported outcomes and clinical findings, obtain laboratory tests and imaging, all with the appropriate instruments and relevant to the clinical presentation, for disease monitoring of patients with axSpA. Decide on the frequency of monitoring on an individual basis depending on symptoms, severity, and treatment.
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  • Assessment of treatment response