Canadian Rheumatology Association/Spondyloarthritis Research Consortium of Canada Recommendations for the Management of Axial Spondyloarthritis

Published by Sherry Rohekar on Aug 1, 2024

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Abstract

Language

en

PICOS

PICO 10.1

Population
Children and adolescents with active sacroilitis
Intervention
NSAID monotherapy
Comparator
no treatment
Outcomes

PICO 10.1

Population
Children and adolescents with active enthesitis
Intervention
Treatment with NSAID monotherapy
Comparator
No treatment
Outcomes

PICO 20.1

Population
Children and adolescents with active enthesitis
Intervention
Treatment with NSAID and systemic DMARD/biologic
Comparator
Treatment with DMARD/biologic monotherapy
Outcomes

PICO 20.1

Population
Children and adolescents with active sacroilitis
Intervention
Treatment with NSAID and systemic DMARD/biologic
Comparator
Treatment with systemic DMARD/biologic monotherapy
Outcomes

PICO 20.2

Population
Children and adolescents with active sacroilitis
Intervention
Treatment with NSAID and systemic DMARD/biologic
Comparator
Treatment with systemic DMARD/biologic monotherapy
Outcomes

PICO 20.2

Population
Children and adolescents with active enthesitis
Intervention
Treatment with NSAID and systemic DMARD/biologic
Comparator
Treatment with systemic DMARD/biologic monotherapy
Outcomes

PICO 20.3

Population
Children with enthesitis-related arthritis, only 23% had sacroiliac joint tenderness and/or inflammatory spinal pain at baseline
Intervention
TNFi monotherapy (ETN, ADA, or IFX), csDMARD monotherapy (MTX, SSZ, or LFN), csDMARD + TNFi, NSAIDs and systemic glucocorticoids
Comparator
Outcomes

PICO 20.3

Population
217 Children with enthesitis-related arthritis; only 23% had sacroiliac joint tenderness and/or inflammatory spinal pain at baseline.
Intervention
TNFi monotherapy (ETN, ADA, or IFX), csDMARD monotherapy (MTX, SSZ, or LFN), csDMARD + TNFi, NSAIDs and systemic glucocorticoids
Comparator
Outcomes

PICO 30.1

Population
Children and adolescents with active sacroilitis, despite treatment with NSAID
Intervention
Treatment with Sulfasalazine
Comparator
No treatment
Outcomes

PICO 30.1

Population
Adults with active axSpA
Intervention
Treatment with NSAIDs
Comparator
No treatment with NSAIDs
Outcomes

PICO 30.1

Population
Children and adolescents with active enthesitis, despite treatment with NSAID
Intervention
Treatment with methotrexate
Comparator
Treatment with TNFI
Outcomes

PICO 30.2

Population
Children and adolescents with active enthesitis, despite treatment with NSAID
Intervention
Treatment with methotrexate
Comparator
Treatment with TNFi
Outcomes

PICO 30.3

Population
Children with enthesitis-related arthritis; only 23% had sacroiliac joint tenderness and/or inflammatory spinal pain at baseline
Intervention
TNFi monotherapy (ETN, ADA, or IFX), csDMARD monotherapy (MTX, SSZ, or LFN), csDMARD + TNFi, NSAIDs
Comparator
Outcomes

PICO 30.4

Population
Extended oligoarticular JIA n=60, enthesitis-related arthritis (ERA) n=38 and PsA n=29
Intervention
Etanercept (ETN) 0.8 mg/kg once weekly (maximum 50 mg). All 127 subjects were ≥80% compliant with ETN and 115 (90.6%) were 100% compliant
Comparator
Outcomes

PICO 30.5

Population
Extended oligoarticular JIA n=60, enthesitis-related arthritis (ERA) n=38 and PsA n=29
Intervention
ETN 0.8 mg/kg once weekly (maximum 50 mg). All 127 subjects were ≥80% compliant with ETN and 115 (90.6%) were 100% compliant.
Comparator
Outcomes

PICO 30.6

Population
346 Adult patients diagnosed with JIA in childhood AND who ever received ETN during childhood AND who were assessed at least once in the JUMBO registry. 75 patients had ERA.
Intervention
ETN (no specific dose or duration of treatment required for entry).
Comparator
Outcomes

PICO 30.7

Population
238 patients Age 14.8 SD 2.8 (at baseline)
Intervention
ETN Dose not mentioned
Comparator
Outcomes

PICO 40.1

Population
Adults with active axSpA
Intervention
Continuous treatment with NSAIDs
Comparator
On-demand treatment with NSAIDs
Outcomes

PICO 40.1

Population
Children and adolescents with active enthesitis, despite treatment with NSAID
Intervention
Treatment with methotrexate
Comparator
Treatment with sulfasalazine
Outcomes

PICO 40.1

Population
Children with enthesitis-related arthritis; only 23% had sacroiliac joint tenderness and/or inflammatory spinal pain at baseline
Intervention
TNFi monotherapy (ETN, ADA, or IFX), csDMARD monotherapy (MTX, SSZ, or LFN), csDMARD + TNFi, NSAIDs and systemic glucocorticoids
Comparator
No treatment
Outcomes

PICO 50.1

Population
Children and adolescents with active enthesitis, despite treatment with NSAID
Intervention
Treatment with sulfasalazine
Comparator
Treatment with TNFi
Outcomes

PICO 50.1

Population
Adults with active axSpA
Intervention
NSAIDs
Comparator
NSAIDs
Outcomes

PICO 50.1

Population
Children and adolescents with active sacroilitis, despite treatment with NSAID
Intervention
Treatment with TNFi
Comparator
Treatment with NSAID monotherapy
Outcomes

PICO 50.2

Population
Children and adolescents with active enthesitis, despite treatment with NSAID
Intervention
Treatment with sulfasalazine
Comparator
Treatment with TNFi
Outcomes

PICO 50.3

Population
Children and adolescents with active enthesitis, despite treatment with NSAID
Intervention
Treatment with sulfasalazine
Comparator
Treatment with TNFi
Outcomes

PICO 50.4

Population
Children with enthesitis-related arthritis; only 23% had sacroiliac joint tenderness and/or inflammatory spinal pain at baseline.
Intervention
TNFi monotherapy (ETN, ADA, or IFX), csDMARD monotherapy (MTX, SSZ, or LFN), csDMARD + TNFi, NSAIDs and systemic glucocorticoids
Comparator
Outcomes

PICO 50.5

Population
JIA n=60, ERA n=38, PsA n=29
Intervention
Etanercept (ETN) 0.8 mg/kg once weekly (maximum 50 mg). All 127 subjects were ≥80% compliant with ETN and 115 (90.6%) were 100% compliant
Comparator
Outcomes

PICO 50.6

Population
JIA n=60, ERA n=38, PsA n=29
Intervention
ETN 0.8 mg/kg once weekly (maximum 50 mg). All 127 subjects were ≥80% compliant with ETN and 115
Comparator
Outcomes

PICO 50.7

Population
Adult patients diagnosed with JIA in childhood AND who ever received ETN during childhood AND who were assessed at least once in the JUMBO registry. 75 patients had ERA.
Intervention
ETN (no specific dose or duration of treatment required for entry).
Comparator
Outcomes

PICO 50.8

Population
238 patients Age 14.8 SD 2.8 (at baseline)
Intervention
ETN (Dose not mentioned)
Comparator
Outcomes

PICO 60.1

Population
Adults with active axSpA
Intervention
Systemic corticosteroids
Comparator
No treatment with systemic corticosteroids
Outcomes

PICO 60.1

Population
Children and adolescents with active enthesitis, despite treatment with NSAID
Intervention
Treatment with systemic glucocorticoids
Comparator
Treatment TNFi
Outcomes

PICO 60.1

Population
Children and adolescents with active sacroilitis, despite treatment with NSAID
Intervention
Treatment with systemic corticosteroids
Comparator
No treatment
Outcomes

PICO 60.2

Population
Children and adolescents with active enthesitis, despite treatment with NSAID
Intervention
Treatment with systemic glucocorticoids
Comparator
Treatment with TNFi
Outcomes

PICO 60.3

Population
JIA n=60, ERA n=38, PsA n=29
Intervention
ETN 0.8 mg/kg once weekly (maximum 50 mg). All 127 subjects were ≥80% compliant with ETN and 115 (90.6%) were 100% compliant
Comparator
Outcomes

PICO 60.4

Population
JIA n=60, ERA n=38, PsA n=29
Intervention
ETN 0.8 mg/kg once weekly (maximum 50 mg). All 127 subjects were ≥80% compliant with ETN and 115 (90.6%) were 100% compliant
Comparator
Outcomes

PICO 60.5

Population
346 Adult patients diagnosed with JIA in childhood AND who ever received ETN during childhood AND who were assessed at least once in the JUMBO registry. 75 patients had ERA.
Intervention
ETN (no specific dose or duration of treatment required for entry).
Comparator
Outcomes

PICO 60.6

Population
238 patients Age 14.8 SD 2.8 (at baseline)
Intervention
ETN (Dose not mentioned)
Comparator
Outcomes

PICO 70.1

Population
Children and adolescents with active sacroilitis, despite treatment with NSAID
Intervention
Treatment with systemic corticosteroids
Comparator
Treatment with sulfasalazine
Outcomes

PICO 70.1

Population
Adults with active axSpA
Intervention
TNFI
Comparator
No treatment with TNFI
Outcomes

PICO 80.1

Population
Children and adolescents with active sacroilitis, despite treatment with NSAID
Intervention
Treatment with intraarticular glucocorticoid injections of the sacroiliac joints
Comparator
No treatment
Outcomes

PICO 80.1

Population
8-year-old female with psoriatic arthritis and nail psoriasis
Intervention
Secukinumab 150 mg subcutaneous injection monthly
Comparator
Outcomes

PICO 80.1

Population
Adults with active axSpA
Intervention
TNFI
Comparator
TNFI
Outcomes

PICO 80.2

Population
Children with with refractory enthesitis-related arthritis
Intervention
MR imaging guided sacroiliac joint injections of 20 mg triamcinolone acetonide
Comparator
Outcomes

PICO 80.2

Population
Children (age 2-18) with ERA or JPsA, with failure of 1 or more NSAID/DMARD
Intervention
Subcutaneous Secukinumab 75/150 mg
Comparator
Placebo Treatment
Outcomes

PICO 80.3

Population
Patients (aged 8-18) with active sacroilitis. Most common aetiologies: JIA (84% [1 ERA patient]), IBD (14%),
Intervention
Image-guided glucocorticoid injections of the sacroiliac joint
Comparator
Outcomes

PICO 90.1

Population
Adults with active axSpA
Intervention
Treatment with IL-17i
Comparator
No treatment with IL-17i
Outcomes

PICO 90.1

Population
Children and adolescents with active sacroilitis, despite treatment with NSAID
Intervention
Treatment with intraarticular glucocorticoid injections of the sacroiliac joints
Comparator
Treatment with sulfasalazine
Outcomes

PICO 100.1

Population
Children and adolescents with active sacroilitis, despite treatment with NSAID
Intervention
Treatment with intraarticular glucocorticoid injections of the sacroiliac joints
Comparator
Treatment with TNFi
Outcomes

PICO 100.1

Population
Children and adolescents with active enthesitis (regardless of concomitant medical therapy)
Intervention
Treatment with any form of physical therapy
Comparator
Treatment with no physical therapy
Outcomes

PICO 100.1

Population
Adults with active axSpA
Intervention
Treatment with IL-17i
Comparator
Treatment with TNFi
Outcomes

PICO 110.1

Population
Children with enthesitis-related arthritis; only 23% had sacroiliac joint tenderness and/or inflammatory spinal pain at baseline.
Intervention
TNFi monotherapy (ETN, ADA, or IFX), csDMARD monotherapy (MTX, SSZ, or LFN), csDMARD + TNFi, NSAIDs and systemic glucocorticoids
Comparator
Outcomes

PICO 110.1

Population
Adults with active axSpA
Intervention
Treatment with an oral small molecule
Comparator
No treatment with an oral small molecule
Outcomes

PICO 120.1

Population
Adults with active axSpA
Intervention
Treatment with tofacitinib
Comparator
Treatment with TNFi
Outcomes

PICO 120.1

Population
Children and adolescents with active sacroilitis, despite treatment with NSAID
Intervention
Treatment with TNFi
Comparator
Treatment with systemic corticosteroids
Outcomes

PICO 130.1

Population
Adults with active axSpA
Intervention
Treatment with tofacitinib
Comparator
Treatment with IL-17i
Outcomes

PICO 140.1

Population
Adults with active axSpA despite treatment with NSAIDs and who have contraindications to TNFi
Intervention
non-TNF biologic
Comparator
oral small molecule
Outcomes

PICO 150.1

Population
Children and adolescents with active sacroilitis (regardless of concomitant medical therapy)
Intervention
Treatment with any form of physical therapy
Comparator
Treatment with no physical therapy
Outcomes

PICO 160.1

Population
Adults with active axSpA
Intervention
Different TNFi
Comparator
Adding methotrexate or sulfasalazine
Outcomes

PICO 170.1

Population
Adults with active axSpA
Intervention
Switching to a different TNFi
Comparator
Switching to a non-TNFi biologic
Outcomes

PICO 190.1

Population
Adults with axSpA and isolated active sacroiliitis
Intervention
Treatment with locally administered corticosteroids
Comparator
No treatment with local corticosteroids
Outcomes

PICO 200.1

Population
dults with axSpA with stable axial disease and active enthesitis
Intervention
Locally administered parenteral corticosteroids
Comparator
No treatment with local corticosteroids
Outcomes

PICO 210.1

Population
Adults with axSpA with stable axial disease and active peripheral arthritis
Intervention
Treatment with locally administered parenteral glucocorticoids
Comparator
No local administration of parenteral glucocorticoids
Outcomes

PICO 220.1

Population
Adults with active axSpA
Intervention
Physical therapy
Comparator
No physical therapy
Outcomes

PICO 230.1

Population
Adults with active axSpA
Intervention
Aquatic physical therapy
Comparator
Land-based physical therapy
Outcomes

PICO 240.1

Population
Adults with active axSpA
Intervention
Active physical therapy
Comparator
Passive physical therapy
Outcomes

PICO 250.1

Population
Adults with stable axSpA
Intervention
Continuous treatment with NSAIDs
Comparator
On-demand treatment with NSAIDs
Outcomes

PICO 260.1

Population
Adults with stable axSpA on treatment with TNFi and NSAIDs
Intervention
Continuing with TNFI and NSAIDs
Comparator
Continuing with TNFI alone
Outcomes

PICO 270.1

Population
Adults with stable axSpA on treatment with TNFi and an oral small molecule
Intervention
TNFI and an oral small molecule
Comparator
TNFI alone or oral small molecule alone
Outcomes

PICO 280.1

Population
Adults with stable axSpA on treatment with a biologic
Intervention
Discontinuation of the biologic
Comparator
No discontinuation of the biologic
Outcomes

PICO 290.1

Population
Axial spondyloarthritis patients with low disease activity
Intervention
Dose reduction
Comparator
Continuation
Outcomes

PICO 290.2

Population
Axial spondyloarthritis patients with low disease activity
Intervention
Discontinuation
Comparator
Continuation
Outcomes

PICO 300.1

Population
Adults with stable axSpA on an originator TNFi
Intervention
Originator TNFI
Comparator
Biosimilar TNFI
Outcomes

PICO 310.1

Population
Adults with stable axSpA
Intervention
Physical therapy
Comparator
No physical therapy
Outcomes

PICO 320.1

Population
Adults with either active or stable axSpA on treatment with TNFi
Intervention
Co-treatment with low-dose methotrexate
Comparator
No co-treatment with low-dose methotrexate
Outcomes

PICO 330.1

Population
Adults with active or stable axSpA
Intervention
Unsupervised back exercises
Comparator
No exercise
Outcomes

PICO 340.1

Population
Adults with active or stable axSpA
Intervention
Fall evaluation and counseling
Comparator
No evaluation and counseling
Outcomes

PICO 350.1

Population
Adults with active or stable axSpA
Intervention
Group or individual self-management education
Comparator
No formal self-management education
Outcomes

PICO 360.1

Population
Adults with active or stable axSpA
Intervention
Spinal manipulation
Comparator
No spinal manipulation
Outcomes

PICO 370.1

Population
Adults with active or stable axSpA and advanced hip arthritis
Intervention
Total hip arthroplasty
Comparator
No surgery
Outcomes

PICO 380.1

Population
Adults with active or stable axSpA and severe kyphosis
Intervention
Elective spinal osteotomy
Comparator
No surgery
Outcomes

PICO 390.1

Population
Adults with axSpA
Intervention
Treatment of acute episodes of uveitis by an ophthalmologist
Comparator
No ophthalmologist care
Outcomes

PICO 400.1

Population
Adults with axSpA
Intervention
Prescription of topical corticosteroids for prompt at-home use in the event of eye symptoms
Comparator
No at-home use
Outcomes

PICO 410.1

Population
Adults with axSpA and recurrent attacks of uveitis
Intervention
Treatment with certain biologics
Comparator
Treatment with other biologics
Outcomes

PICO 420.1

Population
Adults with axSpA who develop uveitis while treated with a TNFi
Intervention
Switching the TNFi
Comparator
Continuing the same TNFi
Outcomes

PICO 430.1

Population
Adults with axSpA and inflammatory bowel disease
Intervention
NSAIDs
Comparator
NSAIDs
Outcomes

PICO 440.1

Population
Adults with axSpA and inflammatory bowel disease
Intervention
Treatment with certain biologics
Comparator
Treatment with other biologics
Outcomes

PICO 450.1

Population
Adults with active or stable axSpA
Intervention
Regular interval use and monitoring of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or AS Disease Activity Score (ASDAS)
Comparator
Usual care without monitoring of the BASDAI or ASDAS
Outcomes

PICO 460.1

Population
Adults with axSpA
Intervention
Regular interval use and monitoring of C-reactiveprotein (CRP) levels or erythrocyte sedimentation rate (ESR)
Comparator
Usual care without regular CRP or ESR monitoring
Outcomes

PICO 470.1

Population
Adults with active axSpA
Intervention
Treat-to-target strategy using a target of ASDAS <1.3 (or <2.1)
Comparator
Symptom-prompted treatment
Outcomes

PICO 480.1

Population
Adults with axSpA
Intervention
Screening for osteopenia/osteoporosis with DEXA scanning yearly, every other year, every five years
Comparator
Screening after insufficiency fractures or no screening
Outcomes

PICO 490.1

Population
Adults with axSpA and syndesmophytes or spinal fusion
Intervention
Screening for osteopenia/osteoporosis with DEXA scanning of the hip or other non-spine sites
Comparator
DEXA scanning of the spine
Outcomes

PICO 500.1

Population
Adults with axSpA
Intervention
Screening for cardiac conduction defects with electrocardiogram at diagnosis, yearly, every other year, or every five years
Comparator
No screening
Outcomes

PICO 510.1

Population
Adults with axSpA
Intervention
Screening for valvular heart disease with echocardiogram at diagnosis, yearly, every other year, or every five years
Comparator
No screening
Outcomes

PICO 520.1

Population
Adults with axSpA of unclear activity while on a biologic
Intervention
Obtaining a spinal or pelvis MRI to assess activity
Comparator
Not obtaining an MRI
Outcomes

PICO 530.1

Population
Adults with stable axSpA
Intervention
Obtaining a spinal or pelvis MRI to confirm inactivity
Comparator
Not obtaining an MRI
Outcomes

PICO 540.1

Population
Adults with active or stable axSpA
Intervention
Obtaining repeat spine radiographs at a scheduled interval (e.g., every 2 years)
Comparator
Not obtaining scheduled radiographs
Outcomes

PICO 550.1

Population
Adults with axSpA with clinical enthesitis
Intervention
Obtaining a entheseal ultrasound to confirm enthesitis
Comparator
Not obtaining an ultrasound
Outcomes

PICO 560.1

Population
Adults with axSpA with no clinical enthesitis
Intervention
Obtaining a entheseal ultrasound to detect subclinical enthesitis
Comparator
Not obtaining an ultrasound
Outcomes