ASAS/EULAR RECOMMENDATIONS FOR THE MANAGEMENT OF ANKYLOSING SPONDYLITIS

Background: Therapeutic options for the management of ankylosing spondylitis (AS) have multiplied in recent years. Treatment recommendations are needed.Objectives: To develop evidence based recommendations for the management of AS, as a combined effort of the ''ASessment in AS'' (ASAS) international working group have combined with the European League Against Rheumatism (EULAR)Methods: The multidisciplinary guideline development group comprised 20 rheumatologists and 2 orthopaedic surgeons, representing 16 countries. The group of experts met on two separate occasions, each over a two-day meeting: once to select the topics for recommendations, and again after the literature review was completed to finalise the recommendations. Each participant could contribute up to 15 propositions describing key clinical aspects of AS management. Using a Delphi consensus approach 10 – 15 questions needed to be selected. On that basis a systematic search of Medline, Embase, CINAHL, PEDro, Cochrane Library and HTA reports was performed to obtain scientific evidence for each question. Evidence was categorised by study type. Where possible, outcome data for efficacy, adverse effects and cost-effectiveness were abstracted. The effect size (ES), rate ratio (RR), number needed to treat (NNT) and incremental cost-effectiveness ratio (ICER) were calculated. On that basis, 10 major ''bullets'' were proposed as main recommendations. The strength of recommendation was assessed using the traditional grading scale based on evidence from the literature and a numerical rating scale based on strength of evidence, risk - benefit trade-off and clinical expertise.Results: Through 3 Delphi rounds 10 key treatment questions were generated. They included 29 interventions: NSAIDs (conventional NSAIDs, coxibs, and co-prescription of gastro-protective agents), disease-modifying anti-rheumatic drugs (including sulfasalazine and methotrexate), bisphosphonates, thalidomide, biological therapies (TNF-alpha blockers, IL-1 antagonists), simple analgesics, muscle relaxants and anti-depressants, local and systemic steroids, non-pharmacological therapy (including education, exercise, physiotherapy, psychological intervention, smoking cessation and diet), and surgical interventions. Three general propositions were also considered. Three hundred and eighteen studies were identified from the literature search for the proposed interventions in terms of efficacy, side effects and cost-effectiveness. Research evidence (category I to IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied dependent on category of evidence and expert opinion.Conclusion: Ten key recommendations for the treatment of AS were developed and assessed using a combination of research-based evidence and expert consensus.Citation: Ann Rheum Dis, volume 64, supplement III, year 2005, page 65Session: Advances in spondylarthritis