title: 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis.
abstract: To update and integrate the recommendations for ankylosing spondylitis and the recommendations for the use of tumour necrosis factor inhibitors (TNFi) in axial spondyloarthritis (axSpA) into one set applicable to the full spectrum of patients with axSpA. Following the latest version of the European League Against Rheumatism (EULAR) Standardised Operating Procedures, two systematic literature reviews first collected the evidence regarding all treatment options (pharmacological and non-pharmacological) that were published since 2009. After a discussion of the results in the steering group and presentation to the task force, overarching principles and recommendations were formulated, and consensus was obtained by informal voting. A total of 5 overarching principles and 13 recommendations were agreed on. The first three recommendations deal with personalised medicine including treatment target and monitoring. Recommendation 4 covers non-pharmacological management. Recommendation 5 describes the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice drug treatment. Recommendations 6-8 define the rather modest role of analgesics, and disprove glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for axSpA patents with predominant axial involvement. Recommendation 9 refers to biological DMARDs (bDMARDs) including TNFi and IL-17 inhibitors (IL-17i) for patients with high disease activity despite the use (or intolerance/contraindication) of at least two NSAIDs. In addition, they should either have an elevated C reactive protein and/or definite inflammation on MRI and/or radiographic evidence of sacroiliitis. Current practice is to start with a TNFi. Switching to another TNFi or an IL-17i is recommended in case TNFi fails (recommendation 10). Tapering, but not stopping a bDMARD, can be considered in patients in sustained remission (recommendation 11). The final two recommendations (12, 13) deal with surgery and spinal fractures. The 2016 Assessment of SpondyloArthritis international Society-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Désirée
authors.identifier: http://orcid.org/0000-0002-5781-158X
authors.initials: D
authors.lastname: van der Heijde
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Sofia
authors.identifier: http://orcid.org/0000-0002-8899-9087
authors.initials: S
authors.lastname: Ramiro
authors.affiliation: Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.|Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands.
authors.forename: Robert
authors.initials: R
authors.lastname: Landewé
authors.affiliation: Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Herne, Germany.
authors.forename: Xenofon
authors.initials: X
authors.lastname: Baraliakos
authors.affiliation: Department of Rheumatology, Ghent University and Ghent University Hospital, Ghent, Belgium.
authors.forename: Filip
authors.initials: F
authors.lastname: Van den Bosch
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.|NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal.
authors.forename: Alexandre
authors.identifier: http://orcid.org/0000-0003-1954-0229
authors.initials: A
authors.lastname: Sepriano
authors.affiliation: Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Herne, Germany.
authors.forename: Andrea
authors.initials: A
authors.lastname: Regel
authors.affiliation: Department of Rheumatology, University Hospital Zurich, Zurich Switzerland.
authors.forename: Adrian
authors.initials: A
authors.lastname: Ciurea
authors.affiliation: Diakonhjemmet Hospital, Oslo, Norway.
authors.forename: Hanne
authors.initials: H
authors.lastname: Dagfinrud
authors.affiliation: Paris Descartes University, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.|INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.
authors.forename: Maxime
authors.initials: M
authors.lastname: Dougados
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Floris
authors.initials: F
authors.lastname: van Gaalen
authors.affiliation: Semmelweis University, Budapest, Hungary.
authors.forename: Pál
authors.initials: P
authors.lastname: Géher
authors.affiliation: Department of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Irene
authors.initials: I
authors.lastname: van der Horst-Bruinsma
authors.affiliation: University of Toronto, Toronto, Ontario, Canada.
authors.forename: Robert D
authors.initials: RD
authors.lastname: Inman
authors.affiliation: Patient Research Partner, Amsterdam, The Netherlands.
authors.forename: Merryn
authors.initials: M
authors.lastname: Jongkees
authors.affiliation: Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Herne, Germany.
authors.forename: Uta
authors.initials: U
authors.lastname: Kiltz
authors.affiliation: Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
authors.forename: Tore K
authors.initials: TK
authors.lastname: Kvien
authors.affiliation: Centre for Rheumatology & MRC Centre for Neuromuscular Diseases, University College London, London, UK.
authors.forename: Pedro M
authors.initials: PM
authors.lastname: Machado
authors.affiliation: NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds, UK.|Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK.
authors.forename: Helena
authors.initials: H
authors.lastname: Marzo-Ortega
authors.affiliation: Paris Descartes University, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France.|INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.
authors.forename: Anna
authors.initials: A
authors.lastname: Molto
authors.affiliation: Department of Rheumatology, University Hospital La Paz, IdiPaz, Madrid, Spain.
authors.forename: Victoria
authors.initials: V
authors.lastname: Navarro-Compàn
authors.affiliation: Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Erciyes University, Kayseri, Turkey.
authors.forename: Salih
authors.initials: S
authors.lastname: Ozgocmen
authors.affiliation: NOVA Medical School, NOVA University of Lisbon, Lisboa, Portugal.
authors.forename: Fernando M
authors.initials: FM
authors.lastname: Pimentel-Santos
authors.affiliation: The University of Texas-Health McGovern Medical School, Dallas, USA.
authors.forename: John
authors.identifier: http://orcid.org/0000-0001-5950-0913
authors.initials: J
authors.lastname: Reveille
authors.affiliation: Klinikum Bielefeld, Bielefeld, Germany.|Gent University, Gent, Belgium.|Charité University Medicine, Berlin, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Rudwaleit
authors.affiliation: Department of Rheumatology, Campus Benjamin Franklin, Charité, Berlin, Germany.
authors.forename: Jochen
authors.initials: J
authors.lastname: Sieper
authors.affiliation: Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
authors.forename: Percival
authors.initials: P
authors.lastname: Sampaio-Barros
authors.affiliation: EULAR PARE Patient Research Partner and Chair of EULAR PARE, Berlin, Germany.
authors.forename: Dieter
authors.initials: D
authors.lastname: Wiek
authors.affiliation: Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Herne, Germany.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Braun
mesh_terms: D000700:Analgesics / Q000627:therapeutic use; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D057915:Drug Substitution; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D020381:Interleukin-17 / Q000037:antagonists & inhibitors; D025241:Spondylarthritis / Q000188:drug therapy* / Q000601:surgery; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D000700:Analgesics; D000894:Anti-Inflammatory Agents, Non-Steroidal; D018501:Antirheumatic Agents; D005938:Glucocorticoids; D020381:Interleukin-17; D014409:Tumor Necrosis Factor-alpha
keywords: DMARDs (biologic); NSAIDs; Physcial therapy; Spondyloarthritis; Treatment