Objective: Axial spondyloarthritis (axSpA), encompassing ankylosing spondylitis and non-radiographic axSpA, is a chronic inflammatory disease that imposes a significant burden on patients through pain, stiffness, and potential long-term structural damage to the spine. This review synthesizes the current, state-of-the-art evidence on the management of axSpA, from foundational therapies to advanced biologic treatments and modern strategic approaches.

Methods: A comprehensive literature review was conducted, focusing on influential publications that shape the contemporary standard of care. Sources included the 2019 ACR/SPARTAN/SLR treatment recommendations, pivotal clinical trials, expert reviews on therapeutic mechanisms and outcomes, and meta-analyses of non-pharmacological interventions.

Results: The management of axSpA is built upon a foundation of non-pharmacological interventions, with strong evidence supporting the efficacy of structured exercise programs in improving physical function [8]. NSAIDs remain the first-line pharmacological treatment for symptom control [1]. For patients with an inadequate response to NSAIDs, biologic therapies, particularly TNF-α inhibitors (anti-TNFs), have revolutionized care by providing substantial and rapid improvements in disease activity and quality of life [2, 4]. However, their ability to definitively halt radiographic progression remains a subject of investigation, with structural damage persisting as a key concern [3]. More recent advances include the approval of drugs with different mechanisms of action, such as IL-17 and JAK inhibitors [7]. Furthermore, there is a paradigm shift towards goal-oriented strategies like Treat-to-Target (T2T), an approach validated by the TICOSPA trial, which demonstrated superior outcomes with a tight-control protocol [5, 6].

Conclusion: The therapeutic landscape for axSpA has evolved dramatically, moving beyond simple symptom relief towards a multi-faceted, goal-directed approach. The integration of non-pharmacological methods, established pharmacotherapies, and strategic management frameworks offers the potential to significantly improve patient outcomes. Preventing long-term structural damage, however, remains the critical unmet need guiding future research.

Axial Spondyloarthritis, Ankylosing Spondylitis, Non-radiographic Axial Spondyloarthritis

Ward, M.M.; Deodhar, A.; Gensler, L.S.; Dubreuil, M.; Yu, D.; Khan, M.A.; Haroon, N.; Borenstein, D.; Wang, R.; Biehl, A.; et al. 2019 American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Care Res. 2019, 71, 1285–1299.

Andreu, J.L.; Otón, T.; Sanz, J. Anti-TNF alpha therapy in ankylosing spondylitis: Symptom control and structural damage modification. Reumatol. Clin. 2011, 7, 51–55.

Neerinckx, B.; Lories, R.J. Structural disease progression in axial spondyloarthritis: Still a cause for concern. Curr. Rheumatol. Rep. 2017, 19, 14.

Kocijan, R.; Muschitz, C.; Rech, J. Anti-TNFs in axial spondyloarthritis. Wien. Med. Wochenschr. 2015, 165, 10–13.

Molto, A.; López-Medina, C.; van den Bosch, F.E.; Booren, A.; Webers, C.; Dernis, E.; van Gaalen, F.A.; Soubrier, M.; Claudepierre, P.; Baillet, A.; et al. Efficacy of a tight-control and treat-to-target strategy in axial spondyloarthritis: Results of the open-label, pragmatic, cluster-randomised TICOSPA trial. Ann. Rheum. Dis. 2021, 80, 1436–1444.

Danve, A.; Deodhar, A. Treat-to-target in Axial Spondyloarthritis. What are the issues? Curr. Rheumatol. Rep. 2017, 19, 22.

Ritchlin, C.; Adamopoulos, I.E. Axial spondyloarthritis: New advances in diagnosis and management. BMJ 2021, 372, m4447.

Pécourneau, V.; Degboé, Y.; Barnetche, T.; Cantagrel, A.; Constantin, A.; Ruyssen-Witrand, A. Effectiveness of exercise programs in ankylosing Spondylitis: A meta-analysis of randomized controlled trials. Arch. Phys. Med. Rehabil. 2018, 99, 383–389.e1.