Ann Rheum Dis 65(4): 442-452

PMC: PMC1798102

PMID: 16126791

ASAS/EULAR recommendations for the management of ankylosing spondylitis

R Inman+15 authors

J Zochling, Rheumazentrum‐Ruhrgebiet, St Josefs‐Krankenhaus, Herne, Germany, and Institute of Bone and Joint Research, Royal North Shore Hospital, Sydney, Australia

D van der Heijde, S van der Linden, Department of Internal Medicine, Division of Rheumatology, University Hospital Maastrict and Caphri Research Institute, The Netherlands

R Burgos‐Vargas, Department of Rheumatology, Hospital General de Mexico, Mexico

E Collantes, Servicio de Reumatologia, Hospital Reina Sofia, Cordoba, Spain

J C Davis, Jr, Division of Rheumatology, University of California San Francisco, San Francisco, USA

B Dijkmans, Department of Rheumatology, VU University Medical Centre, Amsterdam, The Netherlands

M Dougados, Service de Rheumatologie B, Hospital Cochin, Paris, France

P Géher, Department of Rheumatology and Physiotherapy, Semmelweis University, Budapest, Hungary

R D Inman, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada

M A Khan, Case Western Reserve University, University, MetroHealth Medical Center, Division of Rheumatology, Cleveland, Ohio, USA

T K Kvien, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway

M Leirisalo‐Repo, Department of Medicine, Division of Rheumatology, Helsinki University Central Hospital, Helsinki, Finland

I Olivieri, Rheumatology Department of Lucania, S Carlo Hospital, Potenza and Madonna delle Grazie Hospital, Matera, Italy

K Pavelka, Institute of Rheumatology, Prague, Czech Republic

J Sieper, Department of Gastroenterology and Rheumatology, Charitè, Campus Benjamin Franklin, Berlin, Germany

G Stucki, Department of Physical Medicine and Rehabilitation, Ludwig‐Maximilians‐University, Munich, Germany

R D Sturrock, Centre for Rheumatic Diseases, University Department of Medicine, Glasgow Royal Infirmary, Glasgow, UK

D Wendling, Service de Rhumatologie, CHU Jean Minjoz, Besancon, France

H Böhm, Department for Orthopaedics, Spinal Surgery and Paraplegiology, Zentralklinik Bad Berka, Bad Berka, Germany

B J van Royen, Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, The Netherlands

J Braun, Bochum University, Rheumazentrum‐Ruhrgebiet, St Josefs‐Krankenhaus, Herne, Germany

Correspondence to: Professor J Braun
Rheumazentrum‐Ruhrgebiet, St Josefs‐Krankenhaus, Landgrafenstr 15, 44652 Herne, Germany; J.Braun@rheumazentrum‐ruhrgebiet.de

J Zochling, Rheumazentrum‐Ruhrgebiet, St Josefs‐Krankenhaus, Herne, Germany, and Institute of Bone and Joint Research, Royal North Shore Hospital, Sydney, AustraliaD van der Heijde, S van der Linden, Department of Internal Medicine, Division of Rheumatology, University Hospital Maastrict and Caphri Research Institute, The NetherlandsR Burgos‐Vargas, Department of Rheumatology, Hospital General de Mexico, MexicoE Collantes, Servicio de Reumatologia, Hospital Reina Sofia, Cordoba, SpainJ C Davis, Jr, Division of Rheumatology, University of California San Francisco, San Francisco, USAB Dijkmans, Department of Rheumatology, VU University Medical Centre, Amsterdam, The NetherlandsM Dougados, Service de Rheumatologie B, Hospital Cochin, Paris, FranceP Géher, Department of Rheumatology and Physiotherapy, Semmelweis University, Budapest, HungaryR D Inman, Toronto Western Hospital and University of Toronto, Toronto, Ontario, CanadaM A Khan, Case Western Reserve University, University, MetroHealth Medical Center, Division of Rheumatology, Cleveland, Ohio, USAT K Kvien, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, NorwayM Leirisalo‐Repo, Department of Medicine, Division of Rheumatology, Helsinki University Central Hospital, Helsinki, FinlandI Olivieri, Rheumatology Department of Lucania, S Carlo Hospital, Potenza and Madonna delle Grazie Hospital, Matera, ItalyK Pavelka, Institute of Rheumatology, Prague, Czech RepublicJ Sieper, Department of Gastroenterology and Rheumatology, Charitè, Campus Benjamin Franklin, Berlin, GermanyG Stucki, Department of Physical Medicine and Rehabilitation, Ludwig‐Maximilians‐University, Munich, GermanyR D Sturrock, Centre for Rheumatic Diseases, University Department of Medicine, Glasgow Royal Infirmary, Glasgow, UKD Wendling, Service de Rhumatologie, CHU Jean Minjoz, Besancon, FranceH Böhm, Department for Orthopaedics, Spinal Surgery and Paraplegiology, Zentralklinik Bad Berka, Bad Berka, GermanyB J van Royen, Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, The NetherlandsJ Braun, Bochum University, Rheumazentrum‐Ruhrgebiet, St Josefs‐Krankenhaus, Herne, GermanyCorrespondence to: Professor J Braun
Rheumazentrum‐Ruhrgebiet, St Josefs‐Krankenhaus, Landgrafenstr 15, 44652 Herne, Germany; J.Braun@rheumazentrum‐ruhrgebiet.de

Accepted 2005 Aug 22.

Abstract

Objective

To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the ‘ASsessment in AS' international working group and the European League Against Rheumatism.

Methods

Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk‐benefit trade‐off, and clinical expertise.

Results

The final recommendations considered the use of non‐steroidal anti‐inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co‐prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non‐pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I–IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion.

Conclusion

Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.

Keywords: ankylosing spondylitis, management, recommendations, evidence based medicine, spondyloarthropathies, ASAS, EULAR

Abstract

Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease characterised by inflammatory back pain due to sacroiliitis and spondylitis, the formation of syndesmophytes leading to ankylosis, and frequently associated with peripheral arthritis, enthesitis, and acute anterior uveitis. Symptoms commonly begin in late adolescence and early adulthood.¹² With an estimated prevalence of 0.9% in northern European white populations³ AS is a significant health burden to the community.

AS has long been a therapeutic challenge for the clinician. Exercise and non‐steroidal anti‐inflammatory drugs (NSAIDs) have been the mainstay of symptom control for decades, but there has until recently been a dearth of disease modifying treatments. The advent of biological treatment is currently revolutionising the management of AS, but too little is known yet about the long term benefits and risks of such treatment. Clearly, these treatments necessitate socioeconomic cost calculations. Moreover, there is a need for rational, evidence based recommendations to guide the physician in the management of AS. The ASsessment in AS (ASAS) international working group has made important contributions to the evaluation and standardisation of assessments in AS in the past decade.⁴⁵

This project is a collaborative effort of ASAS and EULAR with the ultimate objective to contribute to the improvement of outcomes in patients with AS by constructing evidence based management recommendations. To obtain and maintain a high level of intrinsic quality and comparability of this approach, the EULAR standard operating procedures⁶ were followed.

Acknowledgements

We acknowledge the conceptual and financial assistance of EULAR in the development of these recommendations.

Acknowledgements

Abbreviations

AS - ankylosing spondylitis

ASAS - ASsessment in AS

CI - confidence interval

DMARDs - disease modifying antirheumatic drugs

ES - effect size

MRI - magnetic resonance imaging

NRS - numerical rating scale

NSAIDs - non‐steroidal anti‐inflammatory drugs

OA - osteoarthritis

RCT - randomised controlled trial

THA - total hip arthroplasty

TNF - tumour necrosis factor

VAS - visual analogue scale

Abbreviations

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