Treatment
Table 1. Pharmacological Treatment of Adults with Active AS
Evidence
Quality
a
e ACR strongly recommends treatment with NSAIDs over no treatment
with NSAIDs.
Low
e ACR conditionally recommends continuous treatment with NSAIDs
over on-demand treatment with NSAIDs.
Very Low
e ACR does not recommend any particular NSAID as the preferred choice. Moderate-Low
e ACR strongly recommends against treatment with systemic
glucocorticoids.
Very Low
Active AS despite treatment with NSAIDs
e ACR conditionally recommends against treatment with slow-acting
antirheumatic drugs (SAARDs)
Very Low-
Moderate
e ACR strongly recommends treatment with TNFi compared to no
treatment with TNFi.
Moderate
e ACR does not recommend any particular TNFi as the preferred
choice, except for patients with concomitant inflammatory bowel disease or
recurrent iritis.
Moderate
For patients who also have contraindications to TNFi, the ACR
conditionally recommends treatment with a SAARD over treatment with a
non-TNFi biologic.
Very Low-Low
Active AS despite treatment with the first TNFi used
e ACR conditionally recommends treatment with a different TNFi over
adding a SAARD.
Very Low
e ACR conditionally recommends treatment with a different TNFi over
treatment with a non-TNFi biologic.
Very Low
Also with isolated active sacroiliitis despite treatment with NSAIDs
e ACR conditionally recommends treatment with locally administered
parenteral glucocorticoids over no treatment with local glucocorticoids.
Very Low
Stable axial disease and active enthesitis despite treatment with NSAIDs
e ACR conditionally recommends using treatment with locally
administered parenteral glucocorticoids over no treatment with local
glucocorticoids.
Note: Peri-tendon injections of achilles, patellar and quadriceps tendons should
be avoided.
Very Low
Stable axial disease and active peripheral arthritis despite treatment with NSAIDs
e ACR conditionally recommends using treatment with locally
administered parenteral glucocorticoids over no treatment with local
glucocorticoids.
Very Low
a
See Table 10 for GRADE Scores of Quality of Evidence.
