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Axial spondyloarthritis: time to stop the split 10 years on

The 2019 ACR–SAA–SPARTAN treatment recommendations for axial spondyloarthritis incorporate useful advice on new therapies, treatment strategy and the use of imaging. But is it appropriate to still recommend different treatment strategies for non-radiographic and radiographic disease when available evidence suggests they are part of the same clinical spectrum?

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  1. 1.

    Ward, M. M. et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol. (2019).

    Article  PubMed  Google Scholar 

  2. 2.

    Rudwaleit, M. et al. The development of Assessment of SpondyloArthritis International Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann. Rheum. Dis. 68, 777–783 (2009).

    CAS  Article  Google Scholar 

  3. 3.

    van den Berg, R. et al. Agreement between clinical practice and trained central reading in reading of sacroiliac joints on plain pelvic radiographs. Results from the DESIR cohort. Arthritis Rheumatol. 66, 2403–2411 (2014).

    Article  Google Scholar 

  4. 4.

    Zhao, S. S. et al. Comparison of comorbidities and treatment between ankylosing spondylitis and non-radiographic axial spondyloarthritis in the United States. Rheumatology (2019).

    Article  PubMed  Google Scholar 

  5. 5.

    van der Heijde, D. et al. 2016 update of the ASAS–EULAR management recommendations for axial spondyloarthritis. Ann. Rheum. Dis. 76, 978–991 (2017).

    Article  Google Scholar 

  6. 6.

    Glintborg, B. et al. Does a mandatory non-medical switch from originator to biosimilar etanercept lead to increase in healthcare use and costs? A Danish register-based study of patients with inflammatory arthritis. RMD Open (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Gratacos, J. et al. Non-inferiority of dose reduction versus standard dosing of TNF-inhibitors in axial spondyloarthritis. Arthritis Res. Ther. 21, 11 (2019).

    Article  Google Scholar 

  8. 8.

    Rudwaleit, M. et al. MRI in predicting a major clinical response to anti-tumour necrosis factor treatment in ankylosing spondylitis. Ann. Rheum. Dis. 67, 1276–1281 (2008).

    CAS  Article  Google Scholar 

  9. 9.

    Bennett, A. N. et al. Severity of baseline magnetic resonance imaging-evident sacroiliitis and HLA-B27 status in early inflammatory back pain predict radiographically evident ankylosing spondylitis at eight years. Arthritis Rheum. 58, 3413–3418 (2008).

    CAS  Article  Google Scholar 

  10. 10.

    Boers, N. et al. The effect of tumour necrosis factor inhibitors on radiographic progression in axial spondyloarthritis: a systematic literature review. Rheumatology (2019).

    Article  PubMed  Google Scholar 

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The work of X.M. is supported by the Catalan Society of Rheumatology. The work of H.M.-O. is supported by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the UK National Health Service, the NIHR or the UK Department of Health.

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Correspondence to Helena Marzo-Ortega.

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Competing interests

X.M. declares that he has received speaking fees from Novartis, Sanofi and UCB. H.M.-O. declares that she has received research grants, honoraria and/or speaking fees from AbbVie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer and UCB and that she is a co-author of the 2016 ASAS–EULAR management recommendations for axial spondyloarthritis and a medical advisor to the Spondylitis Association of America.

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Michelena, X., Marzo-Ortega, H. Axial spondyloarthritis: time to stop the split 10 years on. Nat Rev Rheumatol 16, 5–6 (2020).

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