The 2022 updated guidelines for axSpA

28 Sep 2022

In the European Alliance of Associations for Rheumatology (EULAR)European Congress of Rheumatology 2022 (EULAR 2022), expertsfrom the Assessment of SpondyloArthritis International Society (ASAS)and the EULAR updated the recommendations for axial spondyloarthritis(axSpA) management.1 The previous guidelines were updated in2016 based on the evidence published in 2009.2 The basis of theserecommendations involves 2 systematic literature reviews regardingthe efficacy and safety of non-pharmacological and non-biologicalinterventions, as well as the efficacy and safety of biological diseasemodifyinganti-rheumatic drugs (bDMARDs) for axSpA.1

Starting with overarching principles which form the basis for therecommendations on axSpA management, 5 overarching principlesremained unchanged from the 2016 recommendations (table 1).1

Each recommendation has a level of evidence (LoE) and a grade ofrecommendation (GoR) assessed from the systematic literature reviewsin accordance with the Oxford Centre for Evidence-based Medicine.3



  • Level 1a refers to evidence from a meta-analysis of randomized controlled trials (RCTs)
  • Level 1b corresponds to at least 1 RCT
  • Level 2a means that there was at least 1 controlled study without randomization
  • Level 2b means that there was at least 1 type of quasi-experimental study
  • Level 3 corresponds to descriptive studies, such as comparative, correlation, or case-control studies 
  • Level 4 refers to expert committee reports or opinions and/orclinical experience of respected authorities
  • Level 5 refers to expert opinion without explicit critical appraisal,or based on physiology, bench research or “first principles”


  • Garde A means consistent level 1 studies
  • Grade B indicates consistent level 2 or 3 studies, or extrapolationsfrom level 1 studies
  • Grade C means level 4 studies, or extrapolations from level 2or 3 studies
  • Grade D reflects level 5 evidence or troublingly inconsistent orinconclusive studies of any level

The 2022 update consists of a total of 15 recommendations; 8 areunchanged from the previous recommendations (#2, 3, 6, 7, 8, 13,14, 15), 3 are minor edits (#1, 4, 5), 2 are significantly updated (#9and 12), and 2 are newly formulated (#10 and 11).1 The updatedrecommendations are listed in table 2.1

The overarching principles and recommendations were sent tothe task force members who added a level of agreement (LoA)anonymously to each of the statements. This was done by anumerical rating scale (0-10) with the anchors “do not agree at all”at 0 and “fully agree” at 10. The average, standard deviation (SD),and range of the LoA per recommendation, as well as thepercentage of participants with a score of at least 8, arepresented below.1

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