New Guidelines Advance Treatment of Axial Spondyloarthritis in Adults and Youth
June 24, 2026 | ACR NewsClinical Practice GuidelinesTreatments
Updated recommendations emphasize evidence-based care, personalized treatment decisions, and alignment across age groups
ATLANTA – New and updated clinical guidelines released today provide comprehensive, evidence-based recommendations for the management of axial spondyloarthritis (axSpA) for both adults and children. The effort includes an update to the 2019 ACR/SAA/SPARTAN treatment guidelines focusing on adults, alongside a newly developed companion guideline focused specifically on juvenile axial spondyloarthritis.
Together, these guidelines offer clinicians and patients clearer directions on diagnostic workup, treatment selection, and long-term disease management, while emphasizing shared decision-making due to ongoing evidence gaps.
“Axial spondyloarthritis is a complex, lifelong condition that requires nuanced and individualized management,” said Liron Caplan, MD, PhD, Associate Professor, Medicine-Rheumatology, and principal investigator. “These updated recommendations bring together the best available evidence and expert consensus to help rheumatologists make informed choices, while also ensuring patients and families remain central to the decision-making process.”
The guidelines distinguish diagnostic pathways for adults versus children and adolescents:
- Adults: Radiographs (X-rays) of the sacroiliac joints remain the preferred initial diagnostic test followed by MRI of the sacroiliac joints.
- Children and adolescents: MRI of the sacroiliac joints without contrast is recommended as the preferred modality, reflecting differences in disease presentation and diagnostic sensitivity in younger populations.
Once axSpA is confirmed:
- First-line therapy: Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for most patients.
- Additional treatment with certain biologic or targeted synthetic disease modifying anti-rheumatic drugs (b/tsDMARDs) is advised as initial therapy for patients with risk of progression or who have had inadequate response to NSAIDs.
For biologic or targeted synthetic therapies:
- TNF inhibitors (TNFi) and IL-17 inhibitors (IL-17i) are equally recommended as initial biologic disease-modifying antirheumatic drugs (bDMARDs).
- Janus kinase inhibitors (JAKi) are also recommended for the treatment of axSpA, but not as the first-line b/tsDMARD therapy.
- No other biologic or targeted synthetic DMARDs are recommended for routine axSpA management.
The guidelines also advise against the use of conventional synthetic DMARDs (csDMARDs) unless peripheral arthritis or extra-musculoskeletal manifestations (EMMs) are present.
If initial biologic or targeted treatments are not effective:
- Switching to a therapy with a different mechanism of action is recommended.
- After failure of two or more therapeutic classes, clinicians should reassess potential causes of non-response, such as adherence issues or non-inflammatory pain.
- In select cases, dose escalation or dual-targeted therapy may be considered.
The presence of EMMs—such as uveitis, inflammatory bowel disease, or psoriasis—significantly influences treatment choice:
- Uveitis or IBD: Monoclonal antibodies against TNF are preferred.
- Psoriasis: IL-17 inhibitors are favored.
- csDMARDs may be added if extra-musculoskeletal disease remains active.
For patients with well-controlled disease:
- Gradual dose reduction of therapy may be considered.
- However, abrupt discontinuation of biologic or targeted therapies is not recommended due to the risk of disease flare.
Pediatric Considerations
While many recommendations align between adult and pediatric populations, the authors note important distinctions in treatment decisions based on differences in disease biology, risk profiles, and long-term considerations in younger patients.
“The introduction of a dedicated guideline for children and adolescents represents a critical step forward,” said Matthew Stoll, MD, PhD, MSCS, Professor of Pediatric Rheumatology at University of Alabama at Birmingham and principal investigator. “By addressing the unique needs of younger patients, we can support earlier diagnosis, more appropriate imaging strategies, and tailored therapies that improve outcomes across the lifespan.”
Given that many recommendations are based on limited or emerging evidence, the guidelines strongly encourage shared decision-making between rheumatologists and patients (and, in pediatric cases, families). This collaborative approach ensures care plans are aligned with patient values, preferences, and clinical circumstances.
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Teri Arnold
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About the American College of Rheumatology
Founded in 1934, the American College of Rheumatology (ACR) is a not-for-profit, professional association committed to advancing the specialty of rheumatology that serves nearly 10,500 physicians, health professionals, researchers and scientists worldwide. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatology professionals are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases.