A few of the main objectives when developing management recommendations for musculoskeletal diseases, including axial spondyloarthritis (axSpA), are to improve patient outcomes, standardize clinical care, and optimize clinical decision making. Guidelines aim to synthesize the latest evidence on treatment efficacy and safety, providing rheumatologists and clinicians with clear, actionable guidance on managing complex, heterogeneous, and chronic conditions. Standardized recommendations facilitate a more uniform approach to clinical care, reducing variability in treatment practices and promoting best practices across diverse healthcare settings.1 These best practices should be adapted to the structure and resources available in each healthcare system.

In the field of axSpA, where treatment strategies have rapidly evolved with the introduction of biologic and targeted therapies in the last 2 decades, up-to-date guidelines are crucial for providing evidence-based clinical decisions, ultimately enhancing patient quality of life and reducing long-term disease complications and disease progression over time.2 Following this line of reasoning, early identification and adequate treatment are priorities for achieving management goals in patients with axSpA.

In this issue of The Journal of Rheumatology, the Canadian Rheumatology Association (CRA) and the Spondyloarthritis Research Consortium of Canada (SPARCC) have released a set of living treatment recommendations for managing axSpA.3 These guidelines provide an advancement in the treatment landscape for axSpA, adopting a living guideline model and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT methodology, facilitating the further integration of new evidence and local adaptation at country level.

One of the primary strengths of these guidelines is their living model. The dynamic nature of this approach ensures that updates to the recommendations are made in real-time as new research becomes available, which is especially valuable in a rapidly evolving field such as axSpA. Additionally, the GRADE-ADOLOPMENT methodology used in these guidelines provides a structured and flexible framework for developing and adapting recommendations based on existing evidence. This approach holds potential for significant efficiency in guideline development, enabling rapid incorporation of medical literature into rheumatological practice.

Another remarkable feature of these guidelines is the emphasis on health equity. Using the PROGRESS-Plus framework—an acronym used to identify characteristics that stratify health opportunities and outcomes, including personal characteristics associated with discrimination, features of relationships, and time-dependent relationships (eg, disadvantages)—the authors have addressed disparities in healthcare access, which are relevant given the diverse target population. This context describes common scenarios seen in other regions of the world,4 bearing in mind factors that may contribute to the variability in the level of care within rheumatology settings, even within the same country. Additional factors comprise the number of rheumatologists, the diversity of training (ie, frequency, content, and quality), the type of healthcare system (ie, private and/or public), and even the extent of immigration. Recognizing social determinants of health, such as rural residency and socioeconomic status, adds a layer of relevance to the guidelines, promoting equitable care across varied patient demographics. In the context of axSpA management, health equity is critical, especially in heterogeneous countries where diverse populations may face different barriers to care. These could include limited access to specialized treatment in rural areas, financial constraints affecting medication affordability, or cultural differences influencing healthcare utilization. Therefore, the incorporation of health equity into treatment recommendations for axSpA is essential to ensure that guidelines are relevant and applicable across various patient demographics.

On the other hand, although the methodology and structural considerations are strengths, certain topics should be taken into consideration. One point is the level of detail within the methodology, particularly in the explanation of the GRADE-ADOLOPMENT process.5 Although well-suited for experienced clinicians, it may prove challenging for practitioners not intimately familiar with this process, potentially limiting its usability. Additionally, as the body of evidence is limited given the gaps of knowledge in certain areas within the field of axSpA, certain conditional recommendations might lack the precise guidance necessary for effective decision making in clinical settings. Therefore, the implementation of these guidelines requires careful clinical judgment considering the relative benefits and risks of these interventions.

Currently, we have several management recommendations available from national and international societies that bring together the body of knowledge in the literature and enable a practical way for implementation in rheumatological practice. Among the various sets of recommendations available, those from the Assessment of SpondyloArthritis international Society–European Alliance of Associations for Rheumatology (ASAS-EULAR)2 and the Pan American League of Associations for Rheumatology (PANLAR)6 are the more recent ones, both published within the past 5 years and with international scopes.

Some similarities and differences emerge in a critical comparison of these guidelines. Similar to the CRA/SPARCC, the PANLAR guidelines also use the GRADE methodology, but they adapt existing guidelines specifically for the Latin American healthcare context, focusing on regional needs, access to treatments, and economic consideration, including the variation of healthcare infrastructure.6 ASAS-EULAR recommendations are structured to provide comprehensive guidance on axSpA management across Europe. They use a robust methodology with evidence summaries and quality ratings, emphasizing clinical applicability across diverse healthcare systems.2 The CRA/SPARCC guidelines adopt a living guideline model, in which recommendations are continuously updated as new evidence emerges. This approach offers an adaptive framework for clinical decision making in a rapidly evolving treatment landscape, as previously mentioned.3

With regard to panel composition and development, all 3 guidelines include multidisciplinary teams, though PANLAR and ASAS-EULAR uniquely involve patient representatives, integrating patient perspectives into the guideline development process. This emphasizes a commitment to patient-centered care and aligns with international best practices.2,6 Additionally, the CRA/SPARCC recommendations collaborate with Cochrane for systematic reviews and methodological support, enhancing the evidence quality.3 ASAS-EULAR also rigorously adheres to GRADE and Appraisal of Guidelines Research and Evaluation (AGREE) frameworks, lending credibility and consistency to its recommendations.2

There are several recommendations that are written in a very similar way for the management of patients with axSpA in all 3 guidelines. These 3 guidelines strongly recommend nonsteroidal antiinflammatory drugs (NSAIDs) as first-line pharmacological treatment for active axSpA, with a preference for continuous over on-demand use to manage symptoms and potentially reduce disease progression. Similarly, all 3 discourage the long-term use of systemic glucocorticoids (GCs) due to the risk of adverse effects. However, PANLAR and ASAS-EULAR allow for localized GC injections in cases of active sacroiliitis when NSAIDs are ineffective, recognizing a role for tailored interventions in specific disease manifestations.2,6

These guidelines converge on the recommendation of tumor necrosis factor inhibitors (TNFi) and interleukin 17 inhibitors (IL-17i) for patients with active axSpA who do not respond adequately to NSAIDs. Notably, the ASAS-EULAR guidelines extend the therapeutic options by prioritizing IL-17i in patients with concomitant psoriasis, reflecting evidence-based refinement in patient subgrouping and precision medicine.2 PANLAR and ASAS-EULAR include Janus kinase inhibitors (JAKi) as alternatives when biologics are contraindicated or inaccessible.2,6 This represents a growing consensus on the use of JAKi in rheumatology, especially in regions with varying drug availability.

ASAS-EULAR and PANLAR both provide detailed guidance on managing extramusculoskeletal manifestations (eg, uveitis and inflammatory bowel disease), recommending specific biologics based on effectiveness for these conditions.2,6 CRA/SPARCC, while also acknowledging extramusculoskeletal manifestations, provides less detailed direction on this front.3

All 3 guidelines recommend switching to biologics with different mechanisms of action (eg, TNFi to IL-17i or vice versa) following primary treatment failure. This approach aligns with the precision medicine paradigm, optimizing therapeutic efficacy based on individual responses. Regarding combination therapy, CRA/SPARCC and ASAS-EULAR discourage the use of conventional synthetic disease-modifying antirheumatic drugs alongside biologics for purely axial disease, except when there is peripheral arthritis.2,3 PANLAR supports a similar position, advising against unnecessary combinations and only endorsing their use when peripheral joint involvement is present.6

Some comments can be made in relation to regional considerations and health equity. CRA/SPARCC focuses on the equitable distribution of resources within Canada, emphasizing universal access to treatments across provinces.3 PANLAR addresses regional disparities in Latin America, where healthcare access can be limited by economic and infrastructural challenges. The guidelines advocate for biosimilars and adaptable treatment pathways to mitigate cost barriers—a reflection of PANLAR’s commitment to practical and equitable healthcare solutions in resource-limited settings such as Latin America.6 ASAS-EULAR underscores a pan-European perspective, considering both high- and low-resource settings within Europe. These guidelines emphasize the importance of tailoring recommendations to national healthcare policies and available resources, making them broadly applicable and adaptable across Europe.2

In summary, all 3 guidelines offer valuable, evidence-based frameworks for axSpA management. CRA/SPARCC’s living guideline model is particularly adaptive to new evidence, whereas PANLAR’s tailored approach addresses specific regional challenges in Latin America.3,6 Meanwhile, ASAS-EULAR provides a comprehensive, up-to-date perspective with recommendations for diverse patient subgroups and extramusculoskeletal manifestations. Taken together, these guidelines represent an international consensus on axSpA management, though each adapts to their population and specific regional context.

International treatment recommendations for axSpA are essential for standardizing and elevating the quality of care across diverse healthcare settings.7 These 3 guidelines provide a comprehensive, evidence-based approach to disease management that clinicians worldwide can adapt to local contexts, ensuring patients receive the most effective and up-to-date treatments available. Moreover, the need for more research and data on axSpA is crucial to advancing our understanding of this complex condition. Additional data in this field would help to improve and refine existing treatment strategies, validate emerging therapies, and address gaps in care, particularly concerning diverse patient populations. By expanding the body of evidence in axSpA, healthcare providers can deliver more personalized and effective interventions, ultimately improving patient outcomes and enhancing their quality of life.

The author declares no funding or support for this work.

WBM has received speaker’s fees and advisory board fees from AbbVie, Amgen, Biopas, Eli Lilly, Janssen, Novartis, and Pfizer.