Treatment of axial SpA (including ankylosing spondylitis)
Leads: Back in Focus Steering Committee section leads: Dr Helena Marzo-Ortega and Prof. Dennis McGonagle.

Treatment of axial SpA (including ankylosing spondylitis)

Treatment of axial spondyloarthritis (SpA), which includes non-radiographic axial spondyloarthritis (nr-axSpA) and ankylosing spondylitis (AS), can include both pharmacological and non-pharmacological therapies.

The National Institute for Health and Care Excellence (NICE) have published two guidelines for axial SpA (nr-axSpA and AS):

  • TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis. Accessible at: www.nice.org.uk/guidance/ta3831
  • Spondyloarthritis in over 16s: diagnosis and management (this covers both axial SpA and psoriatic arthritis). Accessible at: www.nice.org.uk/guidance/ng652

Play the video below to hear about how the NICE TA383 guidance, published in February 2016, differs from previous guidance available for axial SpA.

 

Click here for prescribing information.

 

Key changes in TA3831 from previous guidance for axial SpA (TA1433 and TA2334) include:

  1. TA383 guidance includes severe non-radiographic axial spondyloarthritis, whereas the previous guidance covered severe active AS only.1
  2. It is now recommended that the choice of treatment should be made after discussion between the clinician and the patient about the advantages and disadvantages of the treatments available. This may include considering associated conditions such as extra-articular manifestations (EAMs), whereas previously this was not detailed.1
  3. It is now recommended that patients may receive treatment with a second TNF-alpha inhibitor if the patient cannot tolerate, or their disease has not responded to, treatment with the first TNF-alpha inhibitor, or whose disease has stopped responding after an initial response.1 Previous guidelines considered sequential treatment with TNF-alpha inhibitors as inappropriate, unless they showed intolerance in the first 12 weeks.3,4
  4. TA383 guidance recommends TNF-alpha inhibitor treatment in people whose disease has responded inadequately to, or who cannot tolerate non-steroidal anti-inflammatory drugs (NSAIDs).1 The previous guidance was more specific and recommended that people could only be offered an anti-TNF after two or more NSAIDs taken sequentially for 4 weeks had failed to control symptoms.3,4
  5. Infliximab is now recommended in severe active AS, only if treatment is started with the least expensive infliximab product.1 Previously, infliximab was not recommended in severe active AS.3

The materials below provide further information on the pharmacological and non-pharmacological aspects of treatment and tools to help support your patient goal setting.

Click on this symbol to expand each section and download materials

Treatment Materials

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    Patient education

    When a patient is diagnosed with axial SpA (and/or is about to begin their treatment) it is important to ensure the patient understands:

    • The disease and its chronic features
    • Their treatment options
    • How they can help manage their disease, for instance through exercise and lifestyle changes (e.g. maintaining healthy weight, smoking cessation)
    • What to do if they experience a flare
    • Who they can go to for further information.

     

    National Ankylosing Spondylitis Society (NASS)

    NASS is a registered charity which provides support, advice, and information for people with AS and other forms of axial SpA. You may wish to encourage your patients to become members of NASS.

    They have a comprehensive website (https://nass.co.uk/*) providing information about the disease itself, exercise, and NASS activities; they also have branches across the UK that provide support and regular physiotherapy for people with AS. (https://nass.co.uk/nass-near-you/)*

     

    NASS also have a patient helpline (020 8741 1515 Monday to Friday 9:00-12:00) for questions about medical or lifestyle aspects, and state benefits and work.

     

    *The website is not owned by AbbVie. AbbVie have no responsibility for content of this website.

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    Exercise and physiotherapy

    Patients with axial SpA should be encouraged to exercise on a regular basis.1 Exercise and physiotherapy can help axial SpA patients reduce pain and stiffness, and maintain flexibility and good posture.2

    Home exercises are known to be efficacious in axial SpA and are recommended to patients.1 However, physical therapy should be considered as it is proven to be more effective than home exercises.1 Following diagnosis of axial SpA, a patient should be referred to a specialist physiotherapist to start an individualised, structured exercise programme.3

    AStretch (a group of UK physiotherapists, that steer the management, and improve the understanding of AS) provide training courses for physiotherapists, technicians, gym instructors, and physiotherapy students working in rheumatology on the assessment and management for AS. AStretch website: http://www.astretch.co.uk

    Information for patients

    Further information for patients can be found on the NASS (National Ankylosing Spondylitis Society) website https://nass.co.uk/exercise/*

    NASS also designed an exercise programme specifically for people with ankylosing spondylitis (AS) called Back to Action. Further information can be found here https://nass.co.uk/living-with-as/back-to-action/ *

    NASS also developed a ‘Back to Action’ app free of charge that can be downloaded from the Google Play or Apple App Store.

     

    1. van der Heijde D, et al. Ann Rheum Dis. 2017;76(6):978-91. 2. NASS Looking Ahead. Available at: http://nass.co.uk/campaigning/looking-ahead/. Accessed: July 2017. 3. NICE NG65. Spondyloarthritis in over 16s: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng65/resources/spondyloarthritis-in-over-16s-diagnosis-and-management-pdf-1837575441349. Accessed: July 2017.

    *The website is not owned by AbbVie. AbbVie have no responsibility for content of this website.

     

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    Treatment guidelines

    Please note these guidelines are for information purposes only, you should always refer to national guidelines and your own local protocols and trust guidelines.

     

    UK Guidelines

    National Institute for Health and Care Excellence (NICE)
    Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. Published last: November 2016. Available at: https://www.nice.org.uk/guidance/NG59.* Accessed: July 2017.

    TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis. Technology appraisal guidance [TA383]. Published last: February 2016. Available at: https://www.nice.org.uk/guidance/ta383.* Accessed: July 2017.

    Spondyloarthritis in over 16s: diagnosis and management. NICE guideline [NG65]. Published last: June 2017. Available at: https://www.nice.org.uk/guidance/ng65.* Accessed: July 2017.


    The Scottish Medicines Consortium (SMC)

    The SMC guidelines for treatment of axial spondyloarthritis can be found on the SMC website at http://www.scottishmedicines.org.uk* Accessed: July 2017.

     

    All Wales Medicines Strategy Group (AWMSG)

    The AWMSG guidelines for treatment of axial spondyloarthritis can be found on the AWMSG website at http://www.awmsg.org* Accessed: July 2017.

     

    British Society for Rheumatology (BSR)

    The BSR and British Health Professionals in Rheumatology (BHPR) guideline for the treatment of axial spondyloarthritis (including ankylosing spondylitis) with biologics can be found on the BSR website at: https://academic.oup.com/rheumatology/article/56/2/313/2631549#supplementary-data.* Accessed: July 2017.

     

    International Guidelines

     

    The Assessment of SpondyloArthritis international Society (ASAS)/-European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) also have guidelines available for axial SpA.

     

    ASAS/EULAR

    van der Heijde D, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978-91. Available at: http://ard.bmj.com/content/76/6/978.long.* Accessed: July 2017

     

    ACR

    Ward MM, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2016 Feb;68(2):282-98. Available at: http://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Axial-Spondyloarthritis.* Accessed: July 2017

     

    *This website is not owned by AbbVie. AbbVie have no responsibility for the content of this website

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    Tool: Desk jotter to support patient goal development

    document

    To support effective management of a chronic disease such as axial spondyloarthritis (SpA), it is important for the patients to be involved in decisions around their health and to understand what these means for them. Setting goals can help discuss the impact of the disease on a patient’s life and agree realistic targets for them to see if their treatment is effective

    To support this process the ‘Patient Goal Desk Jotter’ can be used to record the impact of the patient’s condition on different areas of his/her life and agree potential goals for them. If you would like to discuss alternative formats of this material please contact your local AbbVie representative.

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    Physiotherapist module 4: The Treatment of Axial Spondyloarthritis. Best practice for the management of patients

    document

    The final of the four physiotherapist modules, this provides an overview of the goals of treatment in axial SpA patients and the range of treatments available, including pharmacological and non-pharmacological options.

     

    This Back in Focus resource was developed in partnership with NASS, organised and funded by AbbVie.

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    Factsheet: Summary of Pharmacological Guidance and Recommendations for Axial SpA

    document

    This grid provides an 2 page summary of recommendations from NICE guidance, BSR, ASAS/EULAR guidelines and ACR guidelines around pharmacological treatment of axial SpA.

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    Factsheet: Summary of Guidance and Recommendations for Management of EAMs and Peripheral Symptoms in Axial SpA

    document

    This grid provides a 1 page summary of recommendations from NICE guidance, BSR, ASAS/EULAR guidelines and ACR guidelines around management of EAMs and peripheral symptoms in axial SpA patients

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    Factsheet: 2008/2011 NICE Guidance vs 2016 NICE Guidance for Axial SpA

    document

    This factsheet provides a summary of the key changes in the 2016 NICE guidance for axial SpA compared to the 2008/2011 guidance for AS. 

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    Video: Why is it Important for Health Care Professionals to Work Closely with Ophthalmologists, Dermatologists and Gastroenterologists when Managing Patients with Axial Spondyloarthritis (SpA)?

    Play this video to hear why it's important for rheumatology HCPs to work closely with ophthalmologists, dermatologists and gastroenterologists to manage patients with axial SpA and extra-articular manifestations (EAMs).

    Click here for prescribing information.

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    Video: What does the Treatment Section of the Back in Focus Management Pathway Include?

    Play the video to hear about the treatment section of The Management Pathway for Axial SpA from the Back in Focus Steering Committee 

    Click here for prescribing information.

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    Video: The Role of the Physiotherapist

    Play this video to hear about the role of the physiotherapist in the management of axial SpA and how the Back in Focus Management Pathway can support this role

    Click here for prescribing information.

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    The Axial SpA Checklist

    document

    This checklist highlights some of the key considerations healthcare professionals should take into account in their review and treatment of patients with axial SpA.

     

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    EAMs Patient Leaflet

    document

    This leaflet is designed to provide patients diagnosed with axial SpA information on the extra-articular manifestations they might be affected by and to encourage them to seek advice from a healthcare professional if they experience any of the symptoms.

All the materials can be saved and printed directly from the website. If you would like to discuss alternative formats of these materials please contact your local AbbVie representative.

 

The Axial SpA Management Pathway was developed by the Back in Focus Steering Committee; organised and funded by AbbVie

 

References

1. NICE TA343. TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis. Available at: https://www.nice.org.uk/guidance/ta383. Accessed: July 2017.

2. NICE NG65. Spondyloarthritis in over 16s: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng65. Accessed: July 2017.

3. NICE TA143. Adalimumab, etanercept and infliximab for ankylosing spondylitis. (Replaced by TA383).

4. NICE TA233. Golimumab for the treatment of ankylosing spondylitis. (Replaced by TA383).

*The website is not owned by AbbVie. AbbVie have no responsibility for content of this website.