An update in the pharmacological management of axial spondyloarthritis

Significant progress has been made in the diagnosis and management of axial spondyloarthritis (AxSpA) over recent decades. A greater understanding of the immunopathogenesis of the disease has paved the way for the development of targeted treatments. Their efficacy has been demonstrated in randomized controlled trials, meta-analyses and one head-to-head study of biologic DMARDs. Treatment decisions in AxSpA are currently influenced by patient choice, co-morbidity, clinician familiarity and cost.

We review the clinical trials that underpin the evidence base for treatments in AxSpA. We also cover the meta-analyses and head-to-head data that seek to support clinicians in personalizing treatment decisions. Further, we discuss the recent international guidelines that provide clinicians with treatment pathways and guidance.

We conclude that treatment decisions in managing both radiographic and non-radiographic AxSpA should be based on shared decision-making with patients, the clinical effectiveness of drug class, co-morbidity and cost. At present, we have limited head-to-head data to prioritize one drug class over another for first-line treatment but can recommend tumor necrosis factor (TNF), interleukin 17 (IL17) and JAK inhibition as being comparable in terms of clinical, structural and patient-reported outcome measures. Further real-world data may guide treatment decision-making in individual patients.