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Table 1 Recommendations of the Brazilian Society of Rheumatology for the diagnosis and management of axial SpA with their respective levels of evidence, strength of recommendation, and degrees of agreement among experts (interrater reliability)

From: The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019

Clinical questionRecommendationLevel of evidenceStrength of recommendationDegree of agreement
1- What are the clinical criteria for considering someone affected by a spondyloarthritis?The 2009 ASAS criteria should be used to classify patients with axial spondyloarthritis. The diagnosis should be performed by an experienced physician or a rheumatologist.1BA (strong)9.2
2- What is the role of magnetic resonance imaging (MRI) in the initial evaluation of axial SpA?In patients with clinically suspected axial SpA, in which sacroiliac radiography is not conclusive, sacroiliac joints (SIJ) MRI is recommended.1AA (strong)9.0
SIJ MRI scans should be acquired in T1W and STIR and/or T2 fat saturation (FATSAT) sequences. Intravenous MRI contrast (gadolinium) is not recommended routinely.2BB (moderate)9.5
Spine MRI scans are not recommended on a routine basis for the diagnosis of patients with suspected axial SpA and no sacroiliitis on images.1BA (strong)8.5
3 - What is the role of the HLA-B27 in spondyloarthritis?HLA-B27 test is recommended for patients with clinically suspected axial SpA for prognostic reasons (more severe axial involvement, higher risk of anterior uveitis and family history of axial SpA). Although it is frequently used as a diagnostic tool in our population, there is very limited evidence of its value.2AB (moderate)9.2
4 - What is the evidence for the use of physical rehabilitation in patients with axial SpA?Physical rehabilitation programs should be indicated and offered to all patients diagnosed with axial spondyloarthritis during all stages of the disease.1AA (strong)9.8
Programs specifically focused on improving mobility are primarily recommended, although programs focused on improving endurance and cardiorespiratory fitness are also beneficial.2AA (strong)9.6
5 - What is the evidence for the use of glucocorticoids in patients with axial SpA?Long-term use of systemic glucocorticoids to treat axial spondyloarthritis is not recommended.5D (very weak)9.6
Patients with symptomatic peripheral enthesitis can undergo peritendinous glucocorticoid injections. Caution advised because the procedure may increase the risk of rupture, particularly in the Achilles tendon.2AB (moderate)9.2
Patients with isolated buttock pain who are unresponsive to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) may experience short-term benefits from an intra-articular injection of triamcinolone acetate in the sacroiliac joints.2CB (moderate)8.5
6 - In which situations is the continuous use of NSAIDs recommended for patients with axial SpA?NSAIDs should be indicated as the first-line treatment for active and symptomatic axial SpA.1AA (strong)9.8
There is no evidence that a specific NSAID can be considered superior to the other NSAIDs.1AA (strong)9.3
Evidence on the effect of NSAIDs on reducing radiographic progression in patients with axial SpA is conflicting.1BB (moderate)9.3
7 - What is the evidence for the use of synthetic disease-modifying antirheumatic drugs (methotrexate, sulfasalazine and leflunomide) in patients with axial SpA?The use of methotrexate and sulfasalazine is recommended for the treatment of patients with axial SpA when peripheral arthritis is present or in the absence of another pharmacological treatment option due to toxicity, intolerance or contraindications.2AB (moderate)8.4
The routine use of methotrexate or sulfasalazine as a co-medication in patients with axial SpA who are using biologics is not recommended.2BB (moderate)9.6
8 - What evidence of efficacy supports indications for the use of biologics in patients with axial SpA?Based on the opinion of the rheumatologist, the use of biologics (TNFα inhibitors or interleukin-17 inhibitors) to treat active (BASDAI≥4 or ASDAS≥2.1) and symptomatic axial SpA is recommended when the initial treatment with NSAIDs fails (disease persistence, toxicity or contraindications).1AA (strong)8.9
Biologics should be used to treat axial SpA when objective signs of inflammation are detected, such as elevated C-reactive protein (CRP) levels and/or the presence of sacroiliitis on MRI, as these parameters predict the response, particularly in the context of non-radiographic axial SpA.1BA (strong)9.6
Anti-TNF inhibitors (adalimumab, etanercept, golimumab and certolizumab pegol) are recommended for the treatment of non-radiographic axial SpA since they had an evidence-based approval.1BA (strong)9.7
9 - Are there any differences regarding efficacy among the biologic agents to treat axial SpA patients?The biologics TNFα inhibitors and the IL17A inhibitors exhibit similar effect sizes for controlling inflammatory activity in patients with axial SpA.1AA (strong)8.9
10 - Does the safety of biologics differ in patients with axial SpA?The biologics TNFα inhibitors and the IL17A inhibitors have similar effect sizes for the risk of adverse effects and short-term discontinuation.1AA (strong)9.1
11 - Is the use of biological therapy able to reduce structural damage (radiographic progression) in patients with axial SpA?The reduction in the progression rate of structural damage (observed on spinal radiographies) in patients with axial SpA can be observed in the long-term use of TNF inhibitors.2BB (moderate)8.2
A similar effect on radiographic progression seems to be observed with the continuous use of anti-IL17 (secukinumab) but need to be confirmed in long-term studies.2CB (moderate)9.6
12 - What is the evidence regarding efficacy of biologic agents on extra-articular manifestations in patients with axial SpA?In the case of recurrent anterior uveitis or active inflammatory bowel disease in the setting of axial SpA, anti-TNF monoclonal antibodies (infliximab, adalimumab, golimumab, and certolizumab pegol) have shown the best response rates among the biologics. Therefore, it is recommended to choose it, preferably to others.2AB (moderate)9.4
Monoclonal anti-TNF inhibitors (infliximab, adalimumab, golimumab, and certolizumab pegol) and ant-IL17 inhibitors have shown be the most effective, among the biologics, for the control of active psoriasis in the setting of axial SpA. Therefore, it is recommended to choose it, preferably to others.2BB (moderate)9.4
13- What is the evidence that supports the switching among biologic agents in patients with axial SpA?Patients with axial SpA who fail to show an initial response to a biological therapy (primary treatment failure), loss of efficacy (secondary treatment failure) or adverse effects may switch to another approved biologic, regardless mechanism of action.2AB (moderate)9.4
After the first biologic switch, the response rates decrease slightly but remain significant. The little available evidence on the second biologic switch suggest response rates even lower than the second-line treatment.2AB (moderate)9.1
14 - For how long should a biologic be used during the follow-up of a patient with axial SpA?In those who have reached the proposed treatment target, for at least 6 months, an attempt may be made to reduce the anti-TNFα dose or increase the interval between doses. Data on other mechanisms of action remains insufficient. However, the risk of long-term radiographic progression should be considered.1BB (moderate)8.9
15 - Is there evidence for the use of biologics and/or target-specific small molecules with other mechanisms of action in patients with axial SpA?The use of other biologics and/or target-specific small molecules (abatacept, tocilizumab, rituximab, sarilumab, ustekinumab and apremilast) is not recommended for the treatment of patients with axial SpA.1BA (strong)9.5
The Janus kinase (JAK) inhibitors tofacitinib and filgotinib showed promising clinical results in the treatment of ankylosing spondylitis, but more definitive evidence (phase III randomized clinical trials) is still needed prior to their recommendation.2BB (moderate)9.1