Ann Rheum Dis. Jun 1, 2011; 70(6): 896–904.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions
2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis
1Rheumazentrum Ruhrgebiet, Herne, Germany
2Ruhr-Universität Bochum, Bochum, Germany
3Department of Rheumatology, Leiden University Medical Center, The Netherlands
4Wirbelsäulenzentrum, Bad Berka, Germany
5Department of Rheumatology, Hospital General de México and Faculty of Medicine, Universidad Nacional Autónoma de México, Mexico
6University of Cordoba, Instituto Maimónides de Investigacion Biomédica de Córdoba (IMIBC), Spain
7Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
8University of Oslo, Oslo, Norway
9University of Amsterdam, The Netherlands
10Rheumatology B Department, Cochin Hospital, Descartes University Paris, France
11Section of Musculoskeletal Disease, University of Leeds, Leeds, UK
12University of Budapest, Budapest, Hungary
13Hamad Medical Corporation, Qatar
14University of Toronto, Toronto, Canada
16Case Western Reserve University, Cleveland, Ohio, USA
17Department of Rheumatology, Diakonhjemmet Hospital, University of Oslo, Norway
18Department of Medicine, Division of Rheumatology, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
19University of Alberta, Edmonton, Alberta, Canada
20San Carlo Hospital, Potenza, Italy
21Institute and Clinic of Rheumatology, Charles University of Prague, Prague, Czech Republic
22Department. of Gastroenterology and Rheumatology, Universitaetsmedizin Charité, Berlin, Germany
23Institute of Rheumatology, Warsaw, Poland
24University of Besançon, Besançon, France
25Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Erciyes University, School of Medicine, Kayseri, Turkey
26Department of Orthopaedic Surgery, VU University Medical Center, Amsterdam, The Netherlands
27Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
Accepted March 14, 2011.
The European League against Rheumatism (EULAR) has developed management recommendations for various rheumatic conditions in the past decade1–6
based on standard operating procedures published some years ago.7
The basis for the methodology is the AGREE instrument.8
A systematic literature review (SLR) serves as the basis for the expert discussions and the consensus process.9–11
The Assessments in Ankylosing Spondylitis International Society (ASAS), which published a core set of endpoints for the disease more than 10 years ago12
has taken the lead in developing recommendations for anti-tumour necrosis factor (TNF) therapy in ankylosing spondylitis (AS),13
which have already been updated twice.14 15
The two organisations jointly developed the first set of recommendations for the management of AS together in 2005.
As this is a requirement of the EULAR standard operating procedures for management recommendations and as the field of spondyloarthritis is moving rapidly, an update of the first recommendations for the management of AS is needed after 5 years.
While the first version of the management recommendations was initially developed without patients, and as discrepancies between patients' and physicians' perspectives are well known,16
on this occasion patients were involved in the project group from the beginning. Moreover, other stakeholders, such as physiotherapists, were also represented in the project group. A patient-specific version of the first recommendations has been developed with the active support of patients of many European and North American countries.17
The original and the patient version of the recommendations has been evaluated18 19
and disseminated in several countries.20–23
AS is the prototype,24
a subtype, and an outcome of spondyloarthritis, particularly of the axial form of spondyloarthritis. Recent new classification criteria have widened the spectrum of spondyloarthritis by including earlier forms in addition to AS.25 26
This project has also led to a separation in the classification to predominantly axial and peripheral forms of spondyloarthritis. The term ‘axial spondyloarthritis’ covers patients with chronic back pain who have AS, which is defined by the presence of definite structural changes on radiographs in the sacroiliac joints, and patients with early or abortive forms of spondyloarthritis, which is defined by the presence of sacroiliac inflammation as detected by MRI or the presence of HLA B27 in combination with the presence of features typical of spondyloarthritis.27 28
It can be anticipated that future trials will increasingly target axial spondyloarthritis rather than AS. Some trials with that aim have already been performed and some have started. However, as the evidence from such trials is currently limited it has been decided to restrict the recommendations to AS, although the project group unanimously agreed that these recommendations can equally be applied to patients with axial spondyloarthritis.
As the number of clinical trials and publications on AS therapy has steadily increased over the first decade of the millennium, this provided a sound rationale for a SLR.