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rheum.axial-spondyloarthritis.core.v1PRODUCTION
rheum.axial-spondyloarthritis.core.v1

Axial spondyloarthritis

rheumatologychronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult axial spondyloarthritis spectrum: radiographic axSpA (ankylosing spondylitis, modified New York) ↔ non-radiographic axSpA; same disease continuum, same treatment ladder (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)

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scope confirmed — chronic axial-predominant SpA

Patient inputs (14)

Recurrent uveitis steers biologic choice toward monoclonal-antibody TNFi over IL-17i / etanercept; urgent ophthalmology if active (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)

Active IBD contraindicates IL-17 inhibitors and favours monoclonal TNFi; gastroenterology co-management (ASAS-EULAR 2022)

Inflammatory back pain definition requires onset <45 y; classification arm depends on age at onset (ASAS classification Rudwaleit 2009)

Insidious onset, >3 mo, morning stiffness >30 min, improvement with exercise not rest, night pain (2nd half), alternating buttock pain — drives pretest probability (ASAS-EULAR 2022; Sieper 2009 IBP)

Anchors the ASAS clinical arm (HLA-B27 + ≥2 SpA features) and raises pretest probability (ASAS classification Rudwaleit 2009)

Objective inflammation; elevated CRP is an SpA feature, a poor-prognosis marker, and a component of ASDAS-CRP disease activity (ASAS-EULAR 2022)

Pelvic radiograph (modified New York) defines radiographic AS; MRI SI joints (active osteitis/BME) defines non-radiographic axSpA — the imaging arm of ASAS classification (Rudwaleit 2009)

JAK inhibitors carry boxed MACE/VTE warning; chronic inflammation raises ASCVD; aortitis/conduction disease screen (ASAS-EULAR 2022; ORAL Surveillance Ytterberg NEJM 2022)

Mandatory latent TB (IGRA/TST) + HBV (HBsAg/anti-HBc) screen before any biologic or JAKi; treat latent TB before starting (ASAS-EULAR 2022)

Enthesitis / dactylitis / peripheral arthritis define peripheral domain; csDMARD only helps peripheral, not axial (ASAS-EULAR 2022)

Psoriasis overlaps with psoriatic arthritis sibling and favours IL-17i / TNFi; informs differentiation pivot (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)

Paradoxical low BMD with syndesmophytes; vertebral fracture risk through ankylosed spine — DXA + spine imaging surveillance (ASAS-EULAR 2022)

Acute-phase reactant supporting active inflammation when CRP discordant (ASAS-EULAR 2022)

Certolizumab pegol minimal placental transfer — pregnancy-compatible biologic; NSAID timing relative to conception/3rd trimester (ASAS-EULAR 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningspinal_fracture_through_ankylosed_spine
    Low-energy spinal trauma in known AS / bamboo (ankylosed) spine — high risk of unstable fracture and spinal-cord injury (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcauda_equina_syndrome
    Saddle anaesthesia, bladder/bowel dysfunction, or progressive lower-limb weakness in axSpA (cauda equina or cord compromise) (ACR/SAA/SPARTAN 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_anterior_uveitis
    Acute unilateral painful red eye with photophobia/visual change in axSpA (acute anterior uveitis) (ASAS-EULAR 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaortitis_or_high_grade_av_block
    New aortic regurgitation, ascending aortitis, or high-grade/complete AV block in axSpA (ASAS-EULAR 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebiologic_with_untreated_latent_tb_or_hbv
    Planned bDMARD/JAKi with positive IGRA/TST or HBsAg/anti-HBc without prophylaxis (ASAS-EULAR 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterefractory_high_disease_activity
    ASDAS-CRP ≥3.5 (very high) or sustained ASDAS ≥2.1 despite NSAIDs and ≥1 bDMARD (ASAS-EULAR 2022 treat-to-target)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSoptionalDrives severity classification
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Recommended regimen

axSpA treat-to-target ladder (exercise + NSAID cornerstone → bDMARD by EMM → JAKi → switch)
axis: axspa_treat_to_target_ladderstep 1 - Step 1 — Non-pharmacologic cornerstone + NSAID first-line
Selected step "Step 1 — Non-pharmacologic cornerstone + NSAID first-line" — All confirmed axSpA at diagnosis (radiographic or non-radiographic), any disease activity
  • structured exercise & physiotherapy
    first line
    non_pharmacologic
    n/a • lifelong, regular
    triggers: axspa_confirmed
    ASAS-EULAR 2022 — patient education + regular exercise (home + supervised land/water physiotherapy) is the lifelong cornerstone; preserves mobility and function alongside any pharmacotherapy
  • naproxen
    first line
    NSAID
    500 mg • PO • BID (max: max 1000 mg/day)
    triggers: active_disease, no_active_PUD, no_severe_CKD, acceptable_CV_risk
    ASAS-EULAR 2022 — NSAID first-line; continuous max-tolerated dosing preferred over on-demand when disease active; assess GI/CV/renal risk and add gastroprotection as needed
    rxcui 7258
  • celecoxib
    first line
    NSAID_COX2_selective
    200 mg • PO • once daily–BID (max: max 400 mg/day)
    triggers: GI_risk, NSAID_GI_intolerance
    ASAS-EULAR 2022 — COX-2 selective alternative when GI risk; ≥2 different NSAIDs over ≥4 weeks each before declaring NSAID failure
    rxcui 140587

outpatient playbook — drug actions (6)

  1. 1. structured exercise & physiotherapy
    individualised home + supervised program • n/a • lifelong, regular
    trigger: axSpA confirmed
    ASAS-EULAR 2022 lifelong cornerstone alongside any drug therapy
  2. 2. NSAID (naproxen or celecoxib)
    Naproxen 500 mg BID OR celecoxib 200 mg daily-BID, max tolerated • PO • continuous if active disease
    trigger: Active disease, acceptable GI/CV/renal risk
    ASAS-EULAR 2022 first-line; continuous dosing if active; ≥2 NSAIDs ≥4 wk each before failure
  3. 3. monoclonal TNFi (adalimumab/infliximab/certolizumab)
    Adalimumab 40 mg SC q2wk; infliximab 5 mg/kg IV; certolizumab 400 mg→200 mg q2wk • SC/IV • per agent
    trigger: ASDAS ≥2.1 despite ≥2 NSAIDs AND recurrent uveitis or IBD or pregnancy-planned
    ASAS-EULAR 2022 — monoclonal TNFi preferred with uveitis/IBD; certolizumab if pregnancy
  4. 4. etanercept or IL-17i (secukinumab/ixekizumab)
    Etanercept 50 mg SC weekly; secukinumab 150 mg SC q4wk after loading • SC • per agent
    trigger: Active despite NSAIDs, no IBD/uveitis (IL-17i favoured with psoriasis)
    ASAS-EULAR 2023 — IL-17i alternative first bDMARD; avoid IL-17i in active IBD; etanercept not for uveitis/IBD
  5. 5. switch class or JAK inhibitor (upadacitinib/tofacitinib)
    Upadacitinib 15 mg PO daily; tofacitinib 5 mg PO BID • PO • daily/BID
    trigger: Primary/secondary failure of first bDMARD
    ASAS-EULAR 2023 — switch within/across class or JAKi with boxed MACE/VTE caution (ORAL Surveillance)
  6. 6. sulfasalazine (peripheral only) / local steroid injection
    Sulfasalazine titrate to 1 g BID; triamcinolone 20–40 mg intra-articular/entheseal • PO / injection • per indication
    trigger: Peripheral arthritis or focal enthesitis/sacroiliitis (NOT axial-only)
    ASAS-EULAR 2022 — csDMARD/local steroid for peripheral domain; never systemic steroid for axial

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Chronic inflammatory back pain (insidious onset <45 y, >3 months) (ASAS-EULAR 2022; ASAS IBP criteria Sieper 2009); Enthesitis (Achilles/plantar fascia), dactylitis, or asymmetric lower-limb oligoarthritis (ASAS-EULAR 2022); Acute anterior uveitis, psoriasis, or IBD with chronic back pain (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Axial spondyloarthritis** (rheum.axial-spondyloarthritis.core.v1).
Phenotype framing: Non-radiographic vs radiographic axSpA; peripheral SpA; psoriatic arthritis (axial PsA overlap); reactive arthritis; IBD-associated arthritis; mechanical/degenerative back pain; DISH (Forestier); osteitis condensans ilii; infection (Brodie/discitis); malignancy (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
Scope: Adult axial spondyloarthritis spectrum: radiographic axSpA (ankylosing spondylitis, modified New York) ↔ non-radiographic axSpA; same disease continuum, same treatment ladder (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)

No severity triggers fired against current inputs.

Plan

Regimen axis: **axSpA treat-to-target ladder (exercise + NSAID cornerstone → bDMARD by EMM → JAKi → switch)** — step "Step 1 — Non-pharmacologic cornerstone + NSAID first-line".
1. structured exercise & physiotherapy n/a lifelong, regular (non_pharmacologic, first line) — ASAS-EULAR 2022 — patient education + regular exercise (home + supervised land/water physiotherapy) is the lifelong cornerstone; preserves mobility and function alongside any pharmacotherapy
2. naproxen 500 mg PO BID (NSAID, first line) — ASAS-EULAR 2022 — NSAID first-line; continuous max-tolerated dosing preferred over on-demand when disease active; assess GI/CV/renal risk and add gastroprotection as needed
3. celecoxib 200 mg PO once daily–BID (NSAID_COX2_selective, first line) — ASAS-EULAR 2022 — COX-2 selective alternative when GI risk; ≥2 different NSAIDs over ≥4 weeks each before declaring NSAID failure

Setting playbook (outpatient) — Establish ASAS classification, start exercise + NSAID cornerstone, escalate to bDMARD/JAKi by EMM comorbidity if active despite NSAIDs, treat-to-target ASDAS <2.1 (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
4. structured exercise & physiotherapy individualised home + supervised program n/a lifelong, regular — axSpA confirmed (ASAS-EULAR 2022 lifelong cornerstone alongside any drug therapy)
5. NSAID (naproxen or celecoxib) Naproxen 500 mg BID OR celecoxib 200 mg daily-BID, max tolerated PO continuous if active disease — Active disease, acceptable GI/CV/renal risk (ASAS-EULAR 2022 first-line; continuous dosing if active; ≥2 NSAIDs ≥4 wk each before failure)
6. monoclonal TNFi (adalimumab/infliximab/certolizumab) Adalimumab 40 mg SC q2wk; infliximab 5 mg/kg IV; certolizumab 400 mg→200 mg q2wk SC/IV per agent — ASDAS ≥2.1 despite ≥2 NSAIDs AND recurrent uveitis or IBD or pregnancy-planned (ASAS-EULAR 2022 — monoclonal TNFi preferred with uveitis/IBD; certolizumab if pregnancy)
7. etanercept or IL-17i (secukinumab/ixekizumab) Etanercept 50 mg SC weekly; secukinumab 150 mg SC q4wk after loading SC per agent — Active despite NSAIDs, no IBD/uveitis (IL-17i favoured with psoriasis) (ASAS-EULAR 2023 — IL-17i alternative first bDMARD; avoid IL-17i in active IBD; etanercept not for uveitis/IBD)
8. switch class or JAK inhibitor (upadacitinib/tofacitinib) Upadacitinib 15 mg PO daily; tofacitinib 5 mg PO BID PO daily/BID — Primary/secondary failure of first bDMARD (ASAS-EULAR 2023 — switch within/across class or JAKi with boxed MACE/VTE caution (ORAL Surveillance))
9. sulfasalazine (peripheral only) / local steroid injection Sulfasalazine titrate to 1 g BID; triamcinolone 20–40 mg intra-articular/entheseal PO / injection per indication — Peripheral arthritis or focal enthesitis/sacroiliitis (NOT axial-only) (ASAS-EULAR 2022 — csDMARD/local steroid for peripheral domain; never systemic steroid for axial)

Non-pharmacologic actions:
- Patient education + smoking cessation (smoking accelerates radiographic progression) (ASAS-EULAR 2022)
- Supervised physiotherapy (land + hydrotherapy) and posture program (ASAS-EULAR 2022)
- Co-manage uveitis (ophthalmology), IBD (gastroenterology), psoriasis (dermatology) (ASAS-EULAR 2022)
- Osteoporosis surveillance with DXA; cardiovascular risk reduction (ASAS-EULAR 2022)
- Vaccination update before immunosuppression; no live vaccines on biologic/JAKi (ASAS-EULAR 2022)

AVOID / contraindication checks:
- No systemic glucocorticoids for axial disease local injection only (ASAS EULAR 2022)
- Avoid IL17 inhibitor in active IBD (ASAS EULAR 2023; ACR/SAA/SPARTAN 2019)
- Prefer monoclonal TNFi over etanercept and IL17i in recurrent uveitis (ASAS EULAR 2022)
- JAK inhibitor boxed MACE VTE malignancy serious infection caution (ORAL Surveillance Ytterberg NEJM 2022; ASAS EULAR 2023)
- No biologic or JAKi with untreated latent TB or active HBV (ASAS EULAR 2022)
- No live vaccines during biologic or JAKi therapy (ASAS EULAR 2022)
- CsDMARDs ineffective for axial disease do not use for axial only (ASAS EULAR 2022)
- NSAID block if active PUD or severe CKD or uncontrolled CV disease (ASAS EULAR 2022)
- Certolizumab preferred biologic if pregnancy or conception planned (ASAS EULAR 2022)

Monitoring

Regimen monitoring:
- ASDAS-CRP (or BASDAI) + BASFI q1-3mo until target then q3-6mo (ASAS-EULAR 2022 treat-to-target)
- CRP/ESR each visit as objective inflammation (ASAS-EULAR 2022)
- NSAID GI/renal/CV surveillance — BMP + BP periodically (ASAS-EULAR 2022)
- latent TB screen before biologic then annually (ASAS-EULAR 2022)
- HBV serology before biologic; monitor reactivation if core-Ab positive (ASAS-EULAR 2022)
- JAKi lipid panel + CBC + LFT at baseline and periodically (ORAL Surveillance Ytterberg NEJM 2022)
- DXA at baseline and periodically for paradoxical osteoporosis (ASAS-EULAR 2022)
- spinal mobility (BASMI) + radiographic progression periodically (ASAS-EULAR 2022)

Setting (outpatient) monitoring:
- ASDAS-CRP/BASDAI + BASFI q1-3mo until target then q3-6mo (ASAS-EULAR 2022)
- CRP/ESR each visit (ASAS-EULAR 2022)
- NSAID GI/renal/CV checks; biologic/JAKi safety labs (CBC, LFT, lipids) (ASAS-EULAR 2022; ORAL Surveillance)
- Annual latent TB; HBV reactivation watch (ASAS-EULAR 2022)

Follow-up plan: Lifelong rheumatology follow-up; ongoing exercise/physiotherapy; consider tapering (not abrupt stop) of bDMARD in sustained remission; smoking cessation (accelerates radiographic progression); spine/posture and fall-prevention counselling; uveitis return precautions; vaccination + cardiovascular + bone-health maintenance; hip arthroplasty/spinal osteotomy referral for advanced structural disease (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
- Close-out criterion: long-term plan + multidisciplinary co-management + counselling complete

Monitoring phase: ASDAS-CRP (or BASDAI) + BASFI + CRP every 1–3 mo until target then every 3–6 mo (treat-to-target); NSAID GI/renal/CV surveillance; biologic/JAKi safety (CBC, LFT, lipids for JAKi, latent TB annually, HBV reactivation); periodic spinal mobility (BASMI) + radiographic progression; DXA for paradoxical osteoporosis (ASAS-EULAR 2022 T2T)

Disposition

Current setting: outpatient — Establish ASAS classification, start exercise + NSAID cornerstone, escalate to bDMARD/JAKi by EMM comorbidity if active despite NSAIDs, treat-to-target ASDAS <2.1 (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)

Disposition criteria:
- Continue rheumatology-led outpatient treat-to-target; refer to ED/inpatient only for red-flag complications (ASAS-EULAR 2022)

Escalation triggers (move to higher acuity):
- New severe eye pain/photophobia/redness → urgent same-day ophthalmology for acute anterior uveitis (ASAS-EULAR 2022)
- Low-energy back pain in known AS / bamboo spine → CT spine + immobilise, ED referral for occult fracture (ASAS-EULAR 2022)
- New neurologic deficit / saddle anaesthesia / bladder dysfunction → ED for cauda equina / cord injury (ACR/SAA/SPARTAN 2019)
- New dyspnoea, syncope, diastolic murmur → cardiology for aortitis/aortic regurgitation/AV block (ASAS-EULAR 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Low-energy spinal trauma in known AS / bamboo (ankylosed) spine — high risk of unstable fracture and spinal-cord injury (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019)
- [LIFE_THREATENING] Saddle anaesthesia, bladder/bowel dysfunction, or progressive lower-limb weakness in axSpA (cauda equina or cord compromise) (ACR/SAA/SPARTAN 2019)
- [SEVERE] Acute unilateral painful red eye with photophobia/visual change in axSpA (acute anterior uveitis) (ASAS-EULAR 2022)

Citations

- 2022/2023 ASAS-EULAR axSpA management recommendations + 2019 ACR/SAA/SPARTAN AS/nr-axSpA guideline + ASAS classification criteria [PMID:36270658](https://pubmed.ncbi.nlm.nih.gov/36270658/)
- Cited evidence (PMID 31436036) [PMID:31436036](https://pubmed.ncbi.nlm.nih.gov/31436036/)
- Cited evidence (PMID 19297344) [PMID:19297344](https://pubmed.ncbi.nlm.nih.gov/19297344/)
- Cited evidence (PMID 21540199) [PMID:21540199](https://pubmed.ncbi.nlm.nih.gov/21540199/)
- Cited evidence (PMID 35081280) [PMID:35081280](https://pubmed.ncbi.nlm.nih.gov/35081280/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2022/2023 ASAS-EULAR axSpA management recommendations + 2019 ACR/SAA/SPARTAN AS/nr-axSpA guideline + ASAS classification criteria — PMID:36270658
  • Cited evidence (PMID 31436036) — PMID:31436036
  • Cited evidence (PMID 19297344) — PMID:19297344
  • Cited evidence (PMID 21540199) — PMID:21540199
  • Cited evidence (PMID 35081280) — PMID:35081280