Ep 29. GUIDELINES - BSR axial spondyloarthritis guideline 2025

BSR has published an update to the axial spondyloarthritis guideline.

It's almost 10 years since the last iteration of the guideline. Our understanding and awareness of the disease has increased enormously. We now have 10 different therapies licensed for advanced management of axial spondyloarthritis, which are broadly divided into three different classes: TNF inhibitors, IL17 and JAK inhibitors. 

Join guideline working group Co-Chairs, Karl Gaffney, and Steven Zhao, members William Gregory and Stephanie Harrison, and expert by experience member and CEO of NASS, Dale Webb, in a roundtable discussion hosted by Prof Ernest Choy.

Read the full guideline and download the summary pdf here. 

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Transcript

You're listening to the Talking Rheumatology Podcast, brought to you by the British Society for Rheumatology.

Hello, welcome everyone to this episode of the BSR's Rheumatology Roundtable, where I'll be speaking to the authors of the updated BSR guideline for the treatment of axial spondyloarthritis. I'm Ernest Choy, Editor in Chief of Rheumatology, Oxford. Joining me today are a number of people who have worked on the guideline and I'm going to ask them to introduce themselves in turn.

So first of all, Karl. 

My name is Karl Gaffney. I'm consultant rheumatologist and Professor of rheumatology at Norwich and I've been Chair of the guideline development committee. 

Stephanie. 

Hello, my name is Stephanie Harrison. I'm a rheumatology trainee working in Leeds at the moment and I've been working with the guideline group to do the literature search and to help develop some of the recommendations we'll discuss today.

Steven. 

Steven Zhou, clinical lecturer at the University of Manchester. Had the privilege of co-Chairing with Karl on this guideline and co-first authoring with Stephanie. Hi, I'm Dale Webb, and I'm Chief Exec of the National Axial Spondyloarthritis Society, NASS. Last, but not, least, Will. Hi, I'm Will Gregory, consultant physiotherapist and clinical lead for rheumatology at Salford and I've been supporting the guideline, I suppose, from the physiotherapy background, but also looking at some of the broader elements.

Fantastic. So, welcome everybody. Karl, can you start by giving us an overview of the guideline; why was an update needed and what is new? 

Sure. So thank you very much, Ernest. So we hope that this guideline will provide a practical working framework for the contemporary management of axial spondyloarthritis with advanced therapies.

This guideline has been developed in partnership with the wider rheumatology community. We've had representation from allied health professionals, importantly, other specialties allied to rheumatology like gastroenterology, dermatology and ophthalmology. But, equally importantly, our patient partners and the National Axial Spondyloarthritis Society.

It's almost 10 years since we've had the last iteration of the guideline, and so much has changed in the field of axial spondyloarthritis since then. Our understanding and awareness of the disease has increased enormously. We have a number of new therapies available. So we now have 10 different therapies licensed for advanced management of axial spondyloarthritis, which are broadly divided into three different classes:

TNF inhibitors, IL17 and JAK inhibitors. In the previous version of the guidelines, we only had TNF inhibitors available, and we had very limited data available outside their efficacy on spinal symptoms. So, we thought it was very important to inform the rheumatology community on changes in practice and we hope that these guidelines will be very useful in your day-to-day clinical work.

Okay, fantastic. So, Stephanie, could you explain a little bit about how the guideline was developed? 

Certainly, thank you. So, as Karl's already mentioned, the working group for the guideline was set up in 2023 to review the latest evidence that has been published since the last guideline on the topic from the BSR, which was 2016.

We had 21 members from across the UK covering, not just doctors, but all the allied healthcare professionals we work with on a day to day basis and patients and charity representatives as well. So the scope for our guideline was to review all the new randomized control trial evidence and other relevant literature that have been published since 2016 and to use that to inform updated treatment and management recommendations.

So the main areas we wanted to cover were to review all the latest data on the efficacy and safety of biologic and targeted synthetic DMARDs for axial spondyloarthritis, comparing to placebo, but also comparing one drug to another where there was evidence for that. Other areas that we covered were looking at the use of these medications for extra-musculoskeletal manifestations and we also covered areas such as switching drugs; when or if to use combinations of therapies; as well as strategies, dose tapering and withdrawal, and the use of biosimilars.

We developed a literature search strategy for this with the help of an excellent librarian team at the University of Keele. We eventually ended up with 189 articles which underwent a data extraction, which we shared amongst the team. And it's worth noting all of this was registered prospectively on PROSPERO and followed the PRISMA guidance for best practice for systematic literature review.

And when we had completed all the data extraction, we sat, we got convened as a group and we came up with our recommendations, these were submitted for peer review and also underwent public consultation. We hope that the guideline that we've come up with will be very informative for the rheumatology community and will really help improve the care of patients.

Thank you for that, Stephanie. So the, the recommendations are based on the very extensive review of literature and cover many treatments. Perhaps I can come to Steven and ask him whether he can give us a very quick overview of some of the key recommendations people can find in the guideline, especially how they may differ from the previous version of the guideline.

Thanks, so I think we've already alluded to this, is that we have many more drugs now, but at the back of my mind, I'm still constantly aware that these people with arthritis have many decades of their life for which they need treatment and we actually really only have three drug classes to cycle through. So we really need to be careful in how we choose or more importantly how we don't choose certain therapies.

So we actually spend a lot of the guideline real estate going into the nuances, particularly about extra-musculoskeletal manifestations, because we should say that all three classes are pretty comparable for musculoskeletal features. It is the extra-musculoskeletal manifestations where the key decisions are made.

So we go into, with the help with a lot of input and help from our gastroenterologist, dermatologist and ophthalmologist, to really bring some of that subtlety to light to avoid kind of knee-jerk reactions to say, for example, I can't give an IL17 inhibitor because someone in the distant past had an active history of inflammatory bowel disease, for example.

So that's the first thing I'll say. And the next thing is that Steph alluded to is about treatment strategy. This is new. So, firstly, should we be tapering therapy in people who are in remission? Yes. Should it be stopping therapy? No. Should we be treating to target? And that evidence is less certain in that area, but we certainly should have a conversation with our patients to reach an agreed treatment goal.

I'll end on saying that, we actually opened the guideline with non-pharmacological treatment therapies, even though this was a therapeutic guideline because of how important that is. We don't have space to talk about everything, but we really wanted to put front and centre the fact that we must not forget about these non-pharmacological treatment options, even when we're talking about biologics.

Fantastic. So, Steven, you mentioned that the new guideline is taking into account some of the extra-articular manifestations into consideration. So I want to turn to Dale and ask him how, can you explain how you and other experts by experience were involved in the guidelines development? 

So we were full members of the working group which of course meant that we reviewed the recommendations and made sure that they were supported by the evidence and supported by the lived experience of people.

And also that the recommendations made sense to patients. But I think even more important than that was the conversation about some overarching principles that brought us into a shared space as health professionals and patients. And the sentiment behind those principles I think will be really important for patients to know about.

And so those principles say that: 

-              the primary goal of treatment is to help people lead healthy and productive lives

-              management decisions should be based on a shared decision making process between the patient and the clinician 

-              that we value a holistic approach with an MDT, but also considering non-pharmacological and pharmacological interventions together.

So the sentiment behind those overarching principles, I think, were really important in bringing us into that shared space. 

So what does the guideline mean for patients? How can it benefit people with axial spondyloarthritis? I think both Karl, Steven and yourself mentioned that axial spondyloarthritis, in the main, is a lifelong disease, is something that patient needs to understand themselves. How would this guideline help them? 

I think this will be good news for patients. It will be reassuring to know that a group has been meeting behind the scenes to consider the latest evidence and that therefore that the treatment decisions that the clinician is making with the patient is based upon the best available evidence and that they are a key part of that decision making process.

Great. So I guess the healthcare system is changing and physiotherapists are increasingly being taking on in a very important role in managing patients with axial spondyloarthritis. So I want to turn to Will and ask him, as a physiotherapist, how do you think physiotherapists and other allied health professionals, being a vital part of the MDT in supporting axial spondyloarthritis patients, what are your roles and how do you think this updated guideline will be used by physiotherapists and other allied health professionals?

Well, I think it works in two ways, really. And the first is what you've kind of introduced the way that we are seeing health professionals stepping into more advanced roles across the UK and the delivery of rheumatology services. And we're seeing consultant nurses, consultant AHPs, consultant pharmacists.

So we're looking at a guideline that needs to respect the potential roles that can be taken by health professionals. So I had a little bit of job where some of the drafting came through and said, the rheumatologist could do this, the rheumatologist could do that, just to say, “the rheumatology team”.

However, the key one that stayed in there is coordinated by a rheumatologist. And even where we're seeing advanced and consultant practice by health professionals, it's always within a rheumatology team. So I think it's important that we can develop AHP nursing and pharmacy roles, but also be within an established rheumatology team with support from rheumatologists as a part of that as well.

So if that's one angle, the guideline supporting that advancing role, the other from my physiotherapy background is the crucial role that we know exercise can have for people living with axial spondyloarthritis. It's difficult to have RCTs, and Steph mentioned randomized controlled trials, as the primary piece of evidence we looked at in developing the guidelines, and there are very few, if any, RCTs in exercise for axial spondyloarthritis, so the evidence that we have isn't quite at the level to make it into the guideline.

That doesn't mean we shouldn't be doing it, and we think we should, so it's respecting the role that any exercise professional can have in engaging our patients in keeping as fit and active as we can, as they can, because we know that's a, an anti-inflammatory treatment as well. 

Great. I know that there's a GP in the guideline working group. Will, what do you think are the key things in the guideline for people in primary care to take away? 

Well, I think it relates to that first overarching principle we published, which is our primary goal of treatment for people living with axSpA is to enable them to lead healthy and productive lives, and that therefore gives us a remit for the guideline to cover every version of axial spondyloarthritis, and Karl mentioned kind of advanced therapies, which are probably for those people living with a more severe or advanced version of the condition, but we're seeing a big population of our axial spondyloarthritis cohort who perhaps don't reach that requirement, and therefore they may be more managed in primary care.

So I think the guideline with its scope will increase the knowledge of our primary care colleagues, particularly as they're seeing more MSK work in extended roles. 

Thank you. I'd like to come back to Karl. I see that there are a number of non-rheumatology specialists in the working group, and the guideline is endorsed by the British Society of Gastroenterology. Why was this multi-specialty involvement important and what sort of recommendations can we see in the guideline as a result? 

I think it's very important for us to remember that there are many different aspects to this disease. And one in three of our patients will have an extra-musculoskeletal manifestations, the commonest being uveitis followed by psoriasis and inflammatory bowel disease.

So if we're going to embark on shared decision making and provide optimum care for our patients. It's very important that we have this collaborative approach to management. So it really was essential that we had involvement and we're very grateful to those societies for supporting the work in the development of this guideline.

And I think the evidence is in the table that will be presented in the paper looking at the efficacy of these agents across those musculoskeletal manifestations, because it's very important that we choose the right treatment for an individual patient. As someone's mentioned already, most of these treatments work well for the axial symptoms, but there are very clear distinguishing features when we look at manifestations, and to some extent, the peripheral musculoskeletal manifestations.

So there's rather a lot to consider when choosing. The optimum therapy for an individual patient. 

And finally, how can we support listeners and readers of the guidelines to ensure the recommendations are implemented into clinical practice? I will go to each of the speakers to ask them for their advice. So I'll start off with Steven. 

Yeah, thanks Ernest. So the first thing I'll recommend everybody or the readers and listeners do is go and read the full guideline because we only had the space to talk about more nuanced aspects of management and treatment selection in the full guideline which by necessity had to be distilled down in the summary. We do provide a shorter, in fact very short, version of it for people who are on the go or in the clinic - like a cheat sheet, effectively, of the key recommendations and the indications for certain treatments. We also work with BSR to work on online learning materials. For example e-learning. So: watch this space. 

Thank you, Stephanie. 

Building on what Steve has already mentioned, it's important that we make the guideline accessible for healthcare professionals, but also, if possible, we can produce material for patients and moving forward, we're hoping to work with the BSR and the leading patient charities nationally to try and do that.

Because any treatment decisions we make have to be made in partnership with the patient. Again, watch this space and we hope to produce some material soon to help people in clinic achieve that. 

And how about Dale? 

It's been a really valuable process. And like Stephanie, we're keen to work with BSR to produce a version of this which is accessible and meaningful to patients. And, of course, as part of our ongoing campaigning and lobbying work, making sure that we can embed this in the call for really high quality, consistent rheumatology care across the UK. And we'll just a small chunk of the idea of high quality care that Dale's introduced is thinking about how we deliver this so the guideline does emphasize the importance of AHPs and particularly for me from physiotherapy point of view, have we got enough physiotherapists dedicated to rheumatology, have we got enough space to prioritise this kind of work in musculoskeletal physiotherapy departments, and I hope the guideline will support that with regards to business cases, extra staffing and prioritising it. What we can do for long term conditions like axial spondyloarthritis. 

And I'll ask Karl to wrap up. So thanks very much Ernest. So this has been a very enjoyable experience and just as the Chair of the committee I just want to thank all my co-authors and I said there were 21 of them so it's a big group of people to manage and I'd like to express a huge thanks to Stephanie and Steven who've done the majority of this work and to Lindsay at the BSR for keeping us all in order.

But as a concluding statement, Ernest, I really want to send home the message that this is a practical document that we feel clinicians should refer to in their clinical practice. There's lots of useful information and there's a summary sheet, as Steven says, that is the kind of basic guide. But there's a lot more detail on the nuances of therapies in the full document.

And I think it's really important that clinicians refer to this, particularly in situations where they might be struggling with management or struggling with access to advanced therapies. Because in certain parts of the country, there's still limited access for certain products. So it's very important that they are familiarize themselves with the contemporary evidence and use that to their advantage to support our patients in clinical practice. 

So enjoy reading it and go forth and look after your patients as best as you can. 

Thank you. Fantastic. So I want to thank all the speakers for helping us to understand about the new guidelines on the management of axial spondyloarthritis, bringing us up to date with the management of this condition to help patients to live well.

We have more treatment choices. But our job is to manage the patients right from the community primary care through to the specialist care in a multidisciplinary fashion to enable them to live as full a life as possible. possible. So all the BSR guidelines and linked resources are available from the guideline page on the BSR website.

Thank you to you for joining us to listen to this roundtable and we hope you look forward to more episodes in the future. Thank you.

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